Correspondence
Intravenous tocilizumab in the treatment of resistant optic perineuritis
Optic perineuritis (OPN) is a rare orbital inflammatory disease that mainly involves the optic nerve sheath and surrounding tissues. It is accompanied by eye pain and various levels of optic nerve dysfunction, such as decreased vision, visual field defect, and positive afferent pupillary defect. In contrast to optic neuritis, OPN is not a self-limited disease and always requires treatment.1Retinal pigment epithelium apertures associated with subretinal fluid and acquired vitellifom lesions in non-neovascular age-related macular degeneration
Classic features of non-neovascular age-related macular degeneration (AMD) include drusen, drusenoid retinal pigment epithelial (RPE) detachment, and RPE atrophy. More recent studies have shown that intra- and subretinal fluid also may complicate the non-neovascular form of AMD.1Corneal limbal xanthogranuloma in Erdheim-Chester disease
Adult orbital xanthogranulomatous disease is a rare non-Langerhans cell histiocytic condition with 4 clinical subtypes: adult‐onset xanthogranuloma, adult‐onset asthma with periocular xanthogranuloma, necrobiotic xanthogranuloma (NBX), and Erdheim–Chester disease (ECD). We report, to our knowledge, the first case of ECD with limbal infiltration.Kodamea ohmeri keratitis
Kodamaea ohmeri is a yeast-like fungus and a rare but emerging pathogen.1 It has been identified as the causative organism in fungemia, funguria, endocarditis, cellulitis, and peritonitis, often with high fatality rates.1 To the best of our knowledge, there is only 1 previous report of K. ohmeri keratitis in the literature.2Rare case of extramacular choroidal macrovessel
Choroidal macrovessel (CM) is a rare, mostly unilateral vascular anomaly of the choroidal circulation.1 These abnormally large vessels may cause disturbances in the overlying retinal pigment epithelium (RPE) and the development of subretinal fluid. Some CMs can even masquerade as a choroidal tumour or parasitic infestation.1–3 Reports showing early filling of CMs during indocyanine green angiography (ICGA) suggest that most CMs are arterial in nature.1,3,4 The short posterior ciliary circulation is comprised of a medial and lateral posterior choroidal artery (PCA)5,6; the latter may represent the origin of most CMs and may explain why almost all previously reported CMs arise in the macula.Varied management of idiopathic intracranial hypertension in female-to-male transgender patients
Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure, visual disturbances, papilledema, and headache. There is an association between sex hormone excess and IIH, particularly in patients undergoing hormonal therapy for gender transition.1 The increased androgen concentration during testosterone therapy for gender reassignment presents an opportunity for studying different treatment modalities. First-line treatment of IIH involves dietary changes and a carbonic anhydrase inhibitor such as acetazolamide.A masquerader epidemic: five heterogeneous ocular syphilis presentations
Syphilis is a spirochete infection transmitted through intercourse or congenital infection. Despite declining incidence since the 1990s, ocular syphilis has re-emerged in developed countries.1 We describe 5 distinct presentations of ocular syphilis to promote recognition of this increasingly prevalent disease.Wellness among Canadian ophthalmology resident physicians: a national survey
Residency is a particularly stressful and dynamic period during which learners must balance the demands of patient care, education, and personal responsibilities. Evidence of high levels of burnout among resident physicians has driven the development of initiatives and programs to help address this negative consequence of residency training. As a novel topic in the realm of medical education, more information is required to further characterize the sources of burnout and depression and the nuances of various specialities.Multiple myeloma with concurrent herpes zoster ophthalmicus: a case report
Hyperviscosity syndrome, which typically results from elevated serum levels of monoclonal protein, can present with bleeding, retinopathy, and neurologic symptoms.1 We present a case of hyperviscosity syndrome confounded by herpes zoster reactivation in a patient with newly diagnosed multiple myeloma.Delayed diagnosis of autosomal dominant optic atrophy until seventh decade of life
Autosomal dominant optic atrophy (ADOA) is the most common hereditary optic neuropathy, manifesting in approximately 1 in 50 000 people, and up to 1 in 10 000 in Denmark, owing to a founder mutation.1 Isolated ADOA typically manifests in the first 2 decades of life as bilateral painless progressive vision loss and is therefore mostly diagnosed in childhood to young adulthood. We present a series of 2 older patients, aged 63 and 64 years, who had delayed ADOA diagnosis as proband patients in their families, emphasizing the point that chronological age should not be the sole determining factor for ordering testing for ADOA in cases of unexplained optic neuropathy.Papilledema associated with COVID-19 multisystem inflammatory syndrome in children
Multisystem inflammatory syndrome in children (MIS-C), also called pediatric inflammatory multisystem syndrome, is characterized by a wide range of symptoms and can present a diagnostic challenge given its myriad presentations. On top of the more well-known inflammatory manifestations of MIS-C, recent reports have also surfaced of MIS-C causing increased intracranial pressure.1,2 MIS-C can present similarly to other systemic inflammatory disorders such as Kawasaki disease and can be especially difficult to distinguish from Kawasaki disease if a Kawasaki-like presentation is accompanied by a positive test for coronavirus disease 2019 (COVID-19).Late-onset bilateral epithelial ingrowth following rapid corneal decompensation owing to amantadine
Epithelial ingrowth (EI) can occur at the interface between the flap and the stromal bed of the patient's cornea following laser assisted in situ keratomileusis (LASIK) surgery. The introduction of corneal epithelial cells into the interface can happen during surgery or after the procedure owing to loss of contact inhibition and the presence of a pathway to the interface. Epithelial ingrowth is a relatively uncommon complication, with a reported incidence of 3.9% following primary LASIK and up to 12.8% following enhancement with a flap lift.Late progression of visual loss from ocular quinine toxicity
A 64-year-old Caucasian man was admitted to hospital with acute loss of vision after ingesting at least 3 grams of quinine, risperidone, and paracetamol. His medical history was significant for schizophrenia and nocturnal leg cramps. His usual medications were risperidone and quinine as required. No ophthalmic history was noted. An inpatient examination revealed bilateral no-light-perception vision and grossly constricted visual fields. Electrocardiogram showed sinus rhythm and blood tests, including glucose, haematology, liver, renal, coagulation profiles, and paracetamol levels were normal.Intrastromal voriconazole for refractory infectious crystalline keratopathy associated with Candida pararugosa
Infectious crystalline keratopathy (ICK) is an infrequent complication of long-term topical steroid use following penetrating keratoplasty,1 classically caused by Streptococcus viridans.2 It has been reported in association with local immunosuppression after any ocular surgery (lamellar keratoplasty, cataract surgery, trabeculectomy, corneal cross-liking, and laser in situ keratomileusis), as well as in contact lens wearers, herpetic and Acanthamoeba keratitis, and corneal anaesthesia.3,4 Besides α-haemolytic streptococci,2 multiple additional microorganisms have been causally linked to ICK, including Gram-positive or -negative bacteria, atypical mycobacteria, and fungi,3 most of them bearing biofilm-forming capacity.Cadaveric simulation improves ophthalmology resident confidence and preparedness for emergent ophthalmic procedures
Simulation-based training programs have become an essential tool in medical education.1 Surgical simulation on platforms, including the Eyesi, which are now widely adopted throughout ophthalmology training, reduces intraoperative complication rates.2 Even virtual training utilizing computer graphics and surgical models, which may be lacking in qualities provided by real-life scenarios or cadavers, helps trainees perform faster and with fewer errors compared with trainees who went without virtual training.Corneal imaging with optical coherence tomography assisting the diagnosis of mucolipidosis type IV
Mucolipidosis type IV (MPS-IV, OMIM #252650), a lysosomal storage disorder caused by dysfunctional mucolipin-1, is characterized by neurologic and visual impairment, developmental delay, and achlorhydria. MCOLN1 gene mutation identification is diagnostic but requires clinical suspicion. The latter is challenging, however, because most systemic and ocular findings are nonspecific and rarely evolve simultaneously.1 Bilateral corneal clouding is the earliest hallmark sign of MPS-IV. Unlike in other metabolic causes of corneal opacification, it is owing to preferential accumulation of abnormal material in the corneal epithelium as opposed to other corneal layers.Optical coherence tomography angiography in choroidal metastasis before and after treatment
Choroidal metastases represent the most common intraocular malignant tumor in adults.1 With the advent of optical coherence tomography angiography (OCTA), there is a unique opportunity to visualize choroidal vascular pathologies in more detail using a noninvasive technique concurrent with anatomical evaluation of the retina, retinal pigment epithelium (RPE), and choroid. Depth-selective characterization is one of the most significant advantages of OCTA, allowing better visualization of choroid circulation and, particularly, the choriocapillaris layer, which is the main source of perfusion to the RPE and photoreceptors.Late-onset recurrent Acremonium fungal keratitis after therapeutic penetrating keratoplasty
Fungal keratitis is a prominent cause of blindness worldwide. Therapeutic penetrating keratoplasty (TPK) has been demonstrated as an effective treatment for fungal keratitis that does not respond to antifungal medications. Recurrent fungal infection after TPK is uncommon but occurs typically within 2 weeks after surgery.1Endoscopic cyclophotocoagulation and Kahook Dual Blade trabeculotomy in combination with phacoemulsification
Convenient to perform alongside cataract surgery and relatively safe, minimally invasive glaucoma surgeries (MIGS) are growing in popularity. Few studies have examined the effect and safety of performing combined MIGS.Biopsy of a diffuse anterior chamber angle melanocytoma using a Kahook Dual Blade
A 68-year-old female was referred to the emergency ophthalmology clinic with a pigmented iris lesion and an intraocular pressure (IOP) of 38 in her left eye. Initial clinical assessment revealed the presence of a localized, flat, plaque-like peripheral and midperipheral iris lesion in one quadrant. Pigmented seeding on the rest of the iris surface and associated mild corectopia were observed. There were no notable episcleral sentinel vessels, and there was no iris neovascularization. On gonioscopy, heavy pigment invaded 8 clock hours of the angle (Fig.Crossed-quadrant homonymous hemianopsia in a monocular patient
A 75-year-old male presented to the clinic reporting that upon waking up from a nap 4 days earlier, he noticed he could “only see in certain spots.” He has an ocular history of moderate-stage primary open-angle glaucoma in both eyes, dry eye syndrome, and pseudophakia. He had previously undergone enucleation of his blind, painful right eye due to neovascular glaucoma from a previous central retinal vein occlusion. He was a former smoker, and his medical history is significant for multiple myeloma, bladder cancer, pulmonary embolism, hypertension, and hyperlipidemia.Superior oblique myositis following targeted therapy for papillary thyroid carcinoma
Papillary carcinoma of the thyroid gland (PCTG) constitutes 80%–85% of thyroid cancers globally. Despite early lymphatic invasion, PCTG has a relatively indolent course and rarely metastasizes outside of the neck.1 Metastasis to the brain from PCTG is even more uncommon and usually occurs in the context of widely disseminated disease. While the mainstay of treatment for intracranial metastasis from PCTG includes surgical excision and radiotherapy, recent advances into our understanding of the molecular pathways governing PCTG have facilitated development of novel targeted chemotherapeutics.Simple limbal epithelial transplantation (SLET) in conjunction with keratoplasty for severe congenital corneal opacities
Congenital corneal opacities (CCO) are rare, with an incidence of 1 in 26,000 to 37,000 live births.1,2 There is a wide spectrum of CCO disease severity from mild and small opacities to fully opaque cornea with severe lens involvement and vascularization or conjunctivalization of the cornea. The severe form of CCO is usually associated with large corneal opacity and the presence of extensive superficial corneal vascularization. Such eyes may have conjunctival epithelial ingrowth, which can increase the risk of allograft rejection.Junctional scotoma in moyamoya disease
A 66-year-old Hispanic woman presented to the eye clinic with chronic, progressively worsening vision in the right eye over 2 years associated with right-sided temporal headaches, cutaneous allodynia of the scalp, and jaw claudication. She denied fevers, chills, joint pains, nausea, photophobia, phonophobia, personal history of autoimmune disease, and family history of hereditary ophthalmological diseases. Her ocular history included pterygium removal from the OD. Seven years prior to presentation, she had an episode of light-headedness, blurry vision for 30 minutes, a severe headache, and mild weakness of the left hemiface and left body lasting 2 hours.Senior-Loken syndrome secondary to IQCB1 mutation in association with retinitis pigmentosa
Senior-Loken syndrome (SLS) is a rare autosomal recessive disease characterized by nephronophthisis and early-onset retinal degeneration.1 Nephronophthisis leads to end-stage renal failure. Several genes can cause SLS, including NPHP1-6 and NPHP10.2 We herein report a case of SLS type 5 caused by IQCB1 mutation.
