Horner's syndrome and dissection of the internal carotid artery after chiropractic manipulation of the neck

PURPOSE: To report a case of Horner's syndrome and dissection of the internal carotid artery after chiropractic manipulation of the neck. METHODS: Case report. A 44-year-old woman with no prior ocular or vascular history presented with severe right-sided head and neck pain, ptosis, and miosis following chiropractic treatment for a strained right shoulder muscle. RESULTS: Magnetic resonance angiography of the neck and brain revealed a dissection of the right internal carotid artery as well as a suggestion of subtle dissection in the right vertebral artery. No significant brain abnormalities were noted on magnetic resonance imaging. Pharmacological testing was consistent with preganglionic oculosympathetic damage. CONCLUSION: Acute, painful Horner's syndrome as a manifestation of vascular dissection may be associated with chiropractic manipulation of the neck.     

Intravitreal triamcinolone acetonide treatment for serpiginous choroiditis

PURPOSE: To report the efficacy of intravitreal triamcinolone acetonide injection for acute treatment of a patient with serpiginous choroiditis. METHODS: A 50-year-old male patient with serpiginous choroiditis presenting with the complaint of decreased visual acuity in his right eye for the last 10 days. The best corrected visual acuity (BCVA) of the patient was counting finger from 1 meter. Fundus examination and fundus fluorescein angiography of right eye revealed active macular choroiditis in right eye. Intravitreal triamcinolone acetonide (4 mg/0.1 ml) was injected into vitreous, and the patient was followed with visual acuity testing, intraocular pressure measurement, and fundus examination, including fundus fluorescein angiography. RESULTS: Visual acuity of the patient improved to 20/100 after 2 weeks in spite of the triamcinolone crystals, and to 20/50 after 4 weeks with a single dose intravitreal triamcinolone acetonide injection. Complete resolution of the active lesion has been maintained during the 6 months of follow-up. CONCLUSIONS: Single dose intravitreal triamcinolone acetonide injection is sufficient for controlling the active lesions in serpiginous choroiditis. It needs further evaluation as an alternative treatment for achieving rapid and significant visual acuity recovery.     

Scleral fixation of a capsular tension ring for severe ectopia lentis

A 4-year-old boy with bilateral idiopathic and progressive ectopia lentis had phacoaspiration of the lens and capsular tension ring (CTR) insertion in his left eye. Postoperatively, lens capsule centration remained poor. Single-point scleral fixation of the CTR was performed and centration of the lens capsule achieved. In-the-capsule intraocular lens (IOL) implantation was tried, but excessive IOL manipulation sliced open the capsule at the equator. Anterior vitrectomy and scleral IOL fixation were required. A similar approach was adopted in the right eye with meticulous attention given to gentle maneuvers. The operation was uneventful, with good IOL centration. Three and 11 months after surgery in the right and left eye, respectively, best corrected visual acuity was 20/50 in both eyes. Scleral fixation of the CTR, accompanied by gentle IOL manipulation, is an option to improve IOL centration in patients with severe zonular deficiency.     

Horner's syndrome in dissection of the carotid artery after chiropractic manipulation

CASE REPORT: We report on a 37-year old patient with sudden onset of pain of the right scalp and an ipsilateral small pupil, presenting five weeks after chiropractic manipulation of the neck. METHODS/RESULTS: Pharmacologic pupil testing showed a postganglionic Horner's syndrome on the right side. Magnetic resonance angiography confirmed the diagnosis of a dissection of the right internal carotid artery at a subacute stage. CONCLUSION: There appears to be a causal relationship between carotid artery dissection and the chiropractic manipulation of the cervical spine. Ophthalmological signs played the key role in detecting this complication.     

Intravitreal Triamcinolone Acetonide Treatment for Serpiginous Choroiditis

Purpose: To report the efficacy of intravitreal triamcinolone acetonide injection for acute treatment of a patient with serpiginous choroiditis. Methods: A 50-year-old male patient with serpiginous choroiditis presenting with the complaint of decreased visual acuity in his right eye for the last 10 days. The best corrected visual acuity (BCVA) of the patient was counting finger from 1 meter. Fundus examination and fundus fluorescein angiography of right eye revealed active macular choroiditis in right eye. Intravitreal triamcinolone acetonide (4 mg/0.1 ml) was injected into vitreous, and the patient was followed with visual acuity testing, intraocular pressure measurement, and fundus examination, including fundus fluorescein angiography. Results: Visual acuity of the patient improved to 20/100 after 2 weeks in spite of the triamcinolone crystals, and to 20/50 after 4 weeks with a single dose intravitreal triamcinolone acetonide injection. Complete resolution of the active lesion has been maintained during the 6 months of follow-up. Conclusions: Single dose intravitreal triamcinolone acetonide injection is sufficient for controlling the active lesions in serpiginous choroiditis. It needs further evaluation as an alternative treatment for achieving rapid and significant visual acuity recovery.     

Blindness associated with enlarging mycotic aneurysm after cavernous sinus thrombosis

PURPOSE: We report a patient with an enlarging internal carotid mycotic aneurysm secondary to septic cavernous sinus thrombosis presenting with acute visual loss. DESIGN: Single observational case report. METHODS: Retrospective review of the medical record and review of the literature. RESULTS: A 19-year-old man with residual left sixth nerve palsy and decreased vision in his left eye caused by left cavernous sinus thrombosis secondary to pansinusitis was seen 2 weeks after discharge with acute decreased visual acuity in the right eye. A workup revealed an enlarging left carotid/ophthalmic aneurysm that compressed the optic chiasm and right optic nerve. The patient was taken to the interventional angiography suite, where his left internal carotid artery was occluded endovascularly. The patient's vision improved on discharge. CONCLUSIONS: Visual loss caused by a mycotic carotid aneurysm is an infrequent sequelae after cavernous sinus thrombosis and is not well described in the literature. To our knowledge, this is the first reported case of acute visual loss associated with a mycotic ophthalmic aneurysm. The result of treatment was good in this case, with the patient's visual acuity returning to pretreatment status.     

Central retinal vein occlusion combined with cilioretinal artery occlusion

A healthy 65-year-old man with sudden profound visual loss in his right eye presented with clinical signs of central retinal venous occlusion and retinal whitening, indicative of a cilioretinal arterial obstruction. He had been diagnosed with cilioretinal artery occlusion at a private ophthalmology clinic three days before being referred to our department. On fluorescein angiogram of the affected eye, the proximal portion of the retinal arteries filled with dye 27.3 seconds after injection, indicating a delay in retinal arterial filling. Moreover, the cilioretinal artery did not fill at that phase, but went on to fill 45.1 seconds after injection. Over 63.4 seconds after the filling of the retinal arteries, the laminar flow of the retinal venous vessels appeared. This was not until 90.7 seconds after injection. This patient was elderly, had no systemic diseases, and showed non-ischemic CRVO, prolonged retinal arterial filling on fluorescein angiography, and poor prognosis in visual acuity. His clinical course seemed to favor the pathogenetic hypothesis of a primary arterial affection.     

Cilioretinal artery occlusions following embolization of an artery to an intracranial meningioma

Purpose To report a case in which a prophylactic embolization of a feeder artery to an intarcranial meningioma led to an occlusion of a cilioretinal artery. Design A case report. Methods A 48-year-old man with an intracranial meningioma presented with ocular pain and visual loss in his right eye following embolization of a feeder artery to the meningioma with polyvinyl alcohol. Results Ophthalmoscopy 1 month later showed a cilioretinal artery occlusion which was confirmed by fluorescein angiography. His visual acuity was 0.01 in the right eye. The patient was not treated for his ocular symptoms, and his visual acuity 9 month postoperatively improved slightly to 0.1. Conclusions Our case demonstrated that an occlusion of a retinal artery can be a complication of preoperative embolization of an artery to an intracranial tumor and can lead to severe visual loss.     

Anterior Ischemic Optic Neuropathy in a Patient with Churg-Strauss Syndrome

We describe a patient with Churg-Strauss syndrome who developed unilateral anterior ischemic optic neuropathy. A 54-year-old man with a history of bronchial asthma, allergic rhinitis, and sinusitis presented with sudden decreased visual acuity in his right eye that had begun 2 weeks previously. The visual acuity of his right eye was 20 / 50. Ophthalmoscopic examination revealed a diffusely swollen right optic disc and splinter hemorrhages at its margin. Goldmann perimetry showed central scotomas in the right eye and fluorescein angiography showed remarkable hyperfluorescence of the right optic nerve head. Marked peripheral eosinphilia, extravascular eosinophils in a bronchial biopsy specimen, and an increased sedimentation rate supported the diagnosis of Churg-Strauss syndrome. Therapy with methylprednisolone corrected the laboratory abnormalities, improved clinical features, and preserved vision, except for the right central visual field defect. Early recognition of this systemic disease by ophthalmologists may help in preventing severe ocular complications.     

Melanoma-associated retinopathy with unknown primary site in a Japanese woman

BACKGROUND: We report the clinical features of the first case of a Japanese person with melanoma-associated retinopathy. CASE: A 44-year-old woman complained of photopsia and blurred vision in her right eye, and was treated with steroids for uveitis by an ophthalmologist. She was referred to our hospital for further examination. After one month of treatment, she still complained of photopsia in her right eye. The best corrected visual acuity in the right eye was 0.8 and these was sensitivity loss in the central visual field test. Ophthalmoscopy and fluorescein angiography showed some retinal vasculitis in the right eye. A full-field electroretinogram demonstrated a negative-type electroretinogram (ERG) waveform with attenuation of the b-wave amplitude in the right eye. A dark adaptation test revealed sensitivity loss of the rods. The lymph nodes on the right side of her neck were examined and the diagnosis was made of metastic cutaneous melanoma with unknown primary site; her visual dysfunction was diagnosed as melanoma-associated retinopathy. The retinal inflammation improved after steroid treatment, but her visual dysfunction remained. Chemotherapy and an immunotherapy regimen was begun, but 36 months later she died of metastatic melanoma in the lungs. CONCLUSIONS: A woman treated for uveitis without any prior systemic and ocular diseases was diagnosed with melanoma-associated retinopathy and metastatic melanoma in the cervical lymph nodes of unknown primary origin. The first ocular symptoms were photopsia and blurred vision, not night blindness. ERG was useful for diagnosing this rare ocular condition in an early stage.     

Embolic cilioretinal artery occlusion due to carotid artery dissection

PURPOSE: To report a case of embolic cilioretinal artery occlusion caused by carotid artery dissection. DESIGN: Interventional case report. METHODS: A 38-year-old woman presented with acute visual loss in her right eye. Funduscopy showed a cilioretinal artery occlusion, which was confirmed by a fluorescein angiography. An embolus was found in the distal segment of the vessel. RESULTS: Color Doppler images of right internal carotid artery (ICA) disclosed a pseudolumen, suggesting a diagnosis of carotid dissection. Retrobulbar color Doppler image showed relative low flow velocity in the ophthalmic artery without flow reversal. Magnetic resonance angiography and cerebral angiogram showed total occlusion of the right ICA. Follow-up visual field examination revealed an inferior central defect fed by the cilioretinal artery. CONCLUSION: The pathogenesis of retinal artery occlusion caused by carotid dissection may be embolic or hemodynamic. In our case, a permanent visual defect was related to embolic occlusion of the cilioretinal artery.     

A Case of Idiopathic Central Serous Chorioretinopathy in a 12-year-old Male Treated with Bevacizumab

A 12-year-old male presented with a chief complaint of a 1-month-history of decreased visual acuity in his right eye. The patient had no past history of steroid use or other systemic diseases. On fundus examination, which included fluorescent angiography (FAG) and optical coherence tomography (OCT), the patient was diagnosed with idiopathic central chorioretinopathy, whose clinical course was monitored without any specific treatments. At the time of admission, the best-corrected visual acuity was 0.5 in the right eye and 1.0 in the left eye. On fundoscopy, a serous detachment of 1 disc diameter in size was observed in the posterior pole. According to the FAG and the OCT, serous neurosensory detachment was present. After two months of monitoring the clinical course, the best corrected visual acuity in the right eye was 0.8, and there was improvement of neurosensory retinal detachment. However, OCT detected recurrence after five months, and the corrected visual acuity was decreased to 0.6. Bevacizumab was then injected into the vitreous cavity. Complete resolution of the subretinal fluid resulted eight months later, and the corrected visual acuity improved to 1.0.     

成人Coats病1例

目的:报告成人Coats病1例,并探讨其引起的视网膜病变。方法:病例报告。结果:马来西亚63岁糖尿病患者1例,男,右眼无痛性视力下降1a,视力指数/2英尺,而左眼最佳矫正视力为6/12。右眼眼底表明颞侧后极部出现广泛的视网膜渗出物,可累及黄斑区和鼻侧视盘。异常分布的多区域血管位于黄斑颞侧且呈衰减趋势。眼底荧光血管造影显示,毛细血管扩张在视网膜渗出区域且有荧光素渗漏现象存在。左眼表现正常。根据临床和FFA结果,患者被诊断为成人Coats病,右眼行氩激光光凝治疗。激光后6mo,患者的视力保持在6/120并出现视网膜最小限度的回退。结论:临床和血管造影结果是视网膜毛细血管扩张症的重要诊断依据。渗漏区域激光光凝治疗有利于防止视力丧失。     

成人Coats病1例

目的：报告成人Coats病1例,并探讨其引起的视网膜病变。方法：病例报告。结果：马来西亚63岁糖尿病患者1例,男,右眼无痛性视力下降1a,视力指数/2英尺,而左眼最佳矫正视力为6/12。右眼眼底表明颞侧后极部出现广泛的视网膜渗出物,可累及黄斑区和鼻侧视盘。异常分布的多区域血管位于黄斑颞侧且呈衰减趋势。眼底荧光血管造影显示,毛细血管扩张在视网膜渗出区域且有荧光素渗漏现象存在。左眼表现正常。根据临床和FFA结果,患者被诊断为成人Coats病,右眼行氩激光光凝治疗。激光后6mo,患者的视力保持在6/120并出现视网膜最小限度的回退。结论：临床和血管造影结果是视网膜毛细血管扩张症的重要诊断依据。渗漏区域激光光凝治疗有利于防止视力丧失。     

Branch retinal artery occlusion secondary to dengue fever

Dengue is known to affect the posterior segment of the eye, with a range of hemorrhagic and inflammatory sequelae. A 28-year-old lady convalescing from dengue fever complained of unilateral blurring of inferior visual field. She was evaluated clinically and with fluorescein angiography. Her best-corrected visual acuity was 20/20 bilaterally. Fundus examination revealed a branch retinal artery occlusion in the right eye. Fluorescein angiogram confirmed the clinical diagnosis; and also revealed a late staining and leakage from the affected arterial segment. The patient maintained status quo over a follow-up of six months. We report a major vascular occlusion complicating classic dengue fever even in the absence of severe systemic manifestations.     

A case of diode laser photocoagulation in the treatment of choroidal metastasis of breast carcinoma

To report a single case of improvement on choroidal metastasis of breast cancer after laser photocoagulation. A 52-year-old female patient who complained of visual disturbance of the right eye with multiple states of metastasis of breast carcinoma. On initial examination, the right best-corrected visual acuity was 0.63. Right fundoscopy revealed an elevated mass-like lesion temporal to the macule with serous retinal detachment. The mass had a 3.5-disc diameter. A right fluorescein angiogram revealed hypofluorescence during the prearterial and arteriovenous phase and hyperfluorescence during the venous phase. The venous phase showed almost total masking of background choroidal fluorescence at the elevated lesion because of leakage and neovascularization. The patient was treated 4 times by diode laser photocoagulation in addition to chemotherapy. Fifty days after the diode laser treatments, the funduscopy examination and fluorescein angiogram revealed that the serous retinal detachment had been absorbed, the choroid had become flat, the lesion had been reduced in size and hyperfluorescence. The right best-corrected visual acuity was improved to 0.8. Laser photocoagulation appears not to cause any problems for the patient and may be an efficient treatment for patients with choroidal breast carcinoma.     

Late-onset Citrobacter koseri endophthalmitis with suture exposure after secondary intraocular lens implantation

A 54-year-old male patient was seen in clinic for ocular pain and decreased vision in the right eye with duration of two days. He underwent a cataract operation for his right eye 12 years ago, then a sclera-fixated secondary intraocular implantation and pars plana vitrectomy three years ago due to intraocular lens dislocation. At the initial visit, his visual acuity was restricted to the perception of hand motion. An edematous cornea, cells, flare with hypopyon, and exposed suture material at were observed at the six o'clock direction by slit lamp. Vitreous opacity was noted from B-scan ultrasonography. The patient was diagnosed with late-onset endophthalmitis and an intravitreal cocktail injection was done. On the next day, the hypopyon was aggravated, and therefore a pars plana vitrectomy was performed. A vitreous culture tested positive for Citrobacter koseri. After 12 weeks, the best corrected visual acuity of the right eye improved to 0.7 and a fundus examination revealed a relatively normal optic disc and retinal vasculature. We herein report the first case of endophthalmitis caused by Citrobacter koseri in Korea. Exposed suture material was suspected as the source of infection in this case and prompt surgical intervention resulted in a relatively good visual outcome.     

Dramatic response of choroidal neovascularization associated with choroidal osteoma to the intravitreal injection of bevacizumab (Avastin)

PURPOSE: To report the dramatic response of juxtafoveal choroidal neovascularization (CNV) associated with choroidal osteoma to a single intravitreal injection of bevacizumab. METHODS: A 19-year-old female presented with decreased visual acuity and metamorphopsia in her right eye. Best corrected visual acuity assessment, ophthalmic examination, fundus photography, fluorescein angiography, optical coherence tomography (OCT), and high-resolution computed tomography (CT) scan of the orbit was performed. A diagnosis of classic juxtafoveal CNV associated with choroidal osteoma was made. Intravitreal injection of 1.25 mg of bevacizumab was performed. RESULTS: Visual acuity of the right eye was 20/200 before treatment. Visual improvement to 20/25 and the resolution of metamorphopsia was noticed six weeks after the intravitreal injection of bevacizumab. Regression of the CNV was confirmed according to ophthalmoscopic, fluorescein angiographic, and OCT findings. The treatment effect persisted during a 9-month follow-up period. CONCLUSION: The intravitreal injection of bevacizumab can result in the rapid regression of CNV secondary to choroidal osteoma.     

Valsalva Retinopathy Associated With an Oratorical Contest

A 17-year-old man presented to us with a chief complaint of decreased visual acuity accompanied by central scotoma. There was nothing unusual in his medical history other than a recent oratorical contest. At the time of initial diagnosis, the corrected visual acuity was 20/20 in the right eye and 20/100 in the left eye. No significant findings were apparent on ophthalmic evaluation. On fundoscopy, there was a dumbbell-shaped macular bleed with a well-defined margin in the left eye. The clinical course was closely monitored along with drug therapy. Four weeks post presentation, the pre-retinal hemorrhage had nearly resolved. On fluorescein angiography, no significant findings were observed. In the left eye, the corrected visual acuity had improved to 20/25. Valsalva retinopathy is a pathology that occurs when a sudden increase in intra-thoracic pressure or abdominal pressure occurs in an otherwise healthy person. Here we report a case of Valsalva retinopathy occurring following an oratorical contest along with a review of the relevant literature.     

A Case of Radiation Retinopathy of Left Eye After Radiation Therapy of Right Brain Metastasis

A 37-year-old female, who had received modified radical mastectomy for cancer of her right breast, presented with decreased visual acuity in the left eye after radiation therapy for the management of the metastasis to her right brain 14 months ago. After ocular examination, we diagnosed her as radiation retinopathy. At the time of the first visit, the corrected best visual acuity was 0.4 in the left eye, and fundus examination revealed cotton wool spots and cystoid macular edema (CME). The findings in the right eye were normal except for cotton wool spots in the superior major arch. Fluorescein angiography (FA) showed marked telangiectasia and microaneurysms in her left eye but tiny microaneurysms in her right eye. Subsequent optical coherent tomography (OCT) showed CME. We injected intravitreal triamcinolone acetonide (TA). Two weeks after treatment, the visual acuity was improved to 0.6 and the retinal thickness was decreased. Three months later, the visual acuity in the left eye was dropped to 0.3 due to the recurrence of CME, so we injected intravitreal TA again. Five months later, visual acuity was improved to 0.5 and OCT revealed the improvement of CME. The incidence of radiation retinopathy is higher in the side nearer to radiation, but careful radiation blocking is also required on the opposite side of irradiation site considering the possibility of radiation retinopathy and careful observation is required on both sides of the eyes when performing fundus examination.