Correspondence
Paraproteinemic keratopathy: recognizing the ocular significance
Multiple myeloma and its precursor, monoclonal gammopathy of undetermined significance (MGUS), are disorders of plasma cell proliferation and immunoglobulin production. Although an uncommon presentation, paraproteinemic keratopathy, originally called immunotactoid keratopathy,1 may be the first manifestation.2,3 Patients may present with photophobia, glare, and decreased visual acuity or remain asymptomatic with crystals and opacities detected incidentally. Optimal treatment is not yet established, but chemotherapy, superficial keratectomy, and penetrating keratoplasty (PKP) have been reported.Scleral tattoo-induced sarcoid reaction
A 31-year-old Afro-Caribbean woman presented with a 1-week history of bilateral upper and lower eyelid swelling with restriction of eye movements and reduced vision in the right eye. She had had scleral tattooing, subconjunctival injection of dye, performed 13 months earlier on the right side and 9 months earlier on left side, for cosmetic purposes. The subconjunctival dye was purple and green, respectively, and the procedure was performed in the United Kingdom.En face optical coherence tomography for diagnosis of unexplained snowflake scotoma
Ocular conditions with transitory examination findings can be challenging to diagnose, particularly when significant time has elapsed since the acute insult. One such example is paracentral acute middle maculopathy (PAMM), which may present initially with faint gray macular lesions. These lesions fade over time, leaving behind an unrevealing fundus examination and a pattern of inner nuclear layer (INL) thinning that may be difficult to appreciate with typical imaging modalities.1 In this correspondence, we highlight the use of en face optical coherence tomography (OCT) to diagnose a case of perivenular PAMM 6 months after symptom onset, when fundoscopic examination was normal and the patient had already undergone an extensive work-up without a clear diagnosis.Annular pigment ring on the posterior lens capsule: a novel examination finding in blunt ocular trauma
The effects of blunt ocular trauma can impact a wide variety of ocular structures. Trauma may cause dislodgement of iris epithelial cells, which can create a ring of iris pigment on the anterior lens capsule, a finding known as the Vossius ring.1 There has been one previously reported case of an annular pigment ring on the posterior lens capsule following blunt ocular trauma.2Junctional visual field loss: a reappraisal of nomenclature
Historically, junctional visual field loss (JVFL) has been associated with a lesion at the junction of the optic nerve and chiasm, and the most common etiologies are neoplasm and aneurysm.1,2 We present 2 cases of JVFL and review the nomenclature on the various types of scotomas associated with lesions at the junction of the optic nerve and chiasm (e.g., junctional scotoma and junctional scotoma of Traquair). Based on our review of the English-language ophthalmic literature, we believe that our cases are unique and serve to demonstrate the need for expansion of the classification of JVFL.Macular burn secondary to diode laser epilation
Laser epilation is a cosmetic procedure that is becoming more popular in the modern era. Alexandrite (755 nm), diode (810 nm), Nd:YAG (1064 nm), and intense pulsed-light (IPL; 590–1200 nm) lasers are all commonly employed for cosmetic purposes.1 Eye injuries are a serious complication of laser epilation. The increased accessibility of laser epilation devices, their use in places without the proper equipment, and their use by individuals lacking the essential training may result in injuries that result in irreversible vision loss.Evolution of benign episodic pupillary dilation to Adie's tonic pupil
Benign episodic pupillary dilation (BEPD) may cause significant concern for both patients and clinicians alike. In general, BEPD does not require any work-up or further evaluation beyond simple reassurance. We describe a case of BEPD that evolved into a typical neurologically isolated ipsilateral and idiopathic tonic pupil also known as Adie's tonic pupil. After reviewing the PubMed database in search of similar reported cases, we found that this case is a unique presentation in the English-language ophthalmic literature.Visual acuity, patient-reported outcome measures, or both? The development of an evidence-based appropriateness and prioritization tool for cataract surgery patients
Cataracts are the leading cause of blindness worldwide, with surgery as the only effective treatment.1 In Ontario, cataract patients are classified into 4 broad priority levels without clear criteria to help guide clinicians in placing patients into categories 3 and 4. Patients in these 2 categories are generally booked on a first-come, first-served basis and comprise the majority of existing waitlists.2 While visual acuity is objective standard of care and is used in society to categorize patients’ vision, it does not encapsulate other factors impacting visual function.Anaplastic spheno-orbital meningioma: rapid growth after extensive exenteration
Spheno-orbital meningiomas (SOMs) arise from the sphenoid bone and extend into the orbit. These tumours account for approximately 2% of all orbital lesions.1 Presenting symptoms typically include proptosis, diplopia, or optic neuropathy. Most SOMs are CNS World Health Organization (WHO) grade 1 lesions. These are generally considered benign and slow growing. A small proportion of SOMs consists of CNS WHO grade 2 lesions, whereas CNS WHO grade 3 SOMs are very rarely described. These are often called malignant meningiomas.Explantation of iris-sutured intraocular lens
We describe a simple technique for explantation of iris-sutured intraocular lens that aims to reduce the risk of posterior dislocation of the implant at the time of surgery and minimize iatrogenic iris trauma. This technique involves bimanual rotation of the intraocular lens haptic out of the iris stitch.Primitive myxoid mesenchymal tumours of infancy: first case surrounding the optic nerve
Primitive myxoid mesenchymal tumour of infancy is a rare form of sarcoma presenting in infancy.1 It was first described by Alaggio et al.2 in 2006 as a primitive mesenchymal soft tissue sarcoma without any distinctive lineage of differentiation. The tumours described initially occurred on the trunk, head, neck, extremities, chest, scalp, abdomen, back, or limbs.2,3 The tumours initially may be diagnosed as and placed under the broad umbrella of sarcomas, but immunohistochemical and genetic analyses have now categorized the tumour as a definite entity.Ciliochoroidal effusion syndrome associated with mebendazole systemic treatment
Mebendazole (Vermox; Johnson & Johnson Inc, New Brunswick, NJ) is an effective antiparasite drug used for the treatment of Oxyurus vermicularis infections (oxyuriasis).1 Although theoretically considered as a well-tolerated drug with few adverse effects, we report a unique case of transient ciliochoroidal effusion that occurred in temporal association with mebendazole therapy.Updated review: optical coherence tomography findings of the pachychoroid disease spectrum
The ocular choroid consists of 5 distinct layers: innermost Bruch's membrane, capillaries of the choriocapillaris, Sattler's layer housing medium-sized blood vessels, Haller's layer containing larger-sized vessels, and the suprachoroidal space. Pachychoroid disease spectrum (PDS) was first described by Warrow et al.1 in 2013 as a group of chorioretinal disease entities characterized by a thickened choroid exceeding 300 µm and leading to exudative and neovascular complications. However, improved multimodal imaging, including extended depth imaging optical coherence tomography (EDI-OCT), has helped characterize PDS as a spectrum of ocular phenotypes all sharing 3 common characteristics: engorged Haller's layer vessels, Sattler's layer compression, and choriocapillaris attenuation.Allergic conjunctivitis and contact dermatitis following silicone tube intubation
Lacrimal stenting systems have been used to maintain patency of the canaliculi after insults such as surgery, trauma, radiation, and chemotherapy. The first nasolacrimal stents were made of silver wire and used by Graue in 1932.1 Since then, other materials have been used, including silk, nylon, polyethylene, and polypropylene. Modern-day stents are most commonly made of silicone because this material is pliable, affordable, and widely available. Previously thought to be inert, there is evidence that silicone can elicit a foreign-body and inflammatory reaction.Laser-induced maculopathy after iris depigmentation cosmetic treatment
A cosmetic procedure that changes the colour of the eyes using laser therapy against iris melanosomes is being performed in several countries around the world. Some ophthalmologists have expressed concern about this procedure potentially causing glaucoma or uveitis.1 Exposure to laser radiation also may cause visual impairment by retinal injury, sometimes resulting in irreversible damage to the patient.2 We present the first case of a light-induced maculopathy in a patient who underwent an iris depigmentation laser treatment for electively changing the colour of her eyes.Audible blink in carotid-cavernous fistula
A carotid-cavernous fistula (CCF) is an abnormal arteriovenous communication between the carotid artery system and the cavernous sinus. Common ocular manifestations of CCFs include pulsating exophthalmos, conjunctival chemosis, periorbital bruit, diplopia, and ophthalmoplegia.1 We report a patient with atypical CCF who presented with audible blinks and describe the possible pathogenesis of this phenomenon.Ocular findings of oculomotor apraxia/ataxia type 1
Early-onset ataxia with oculomotor apraxia or oculomotor apraxia/ataxia type 1 (AOA-1) is a recessive progressive neurodegenerative disease that is clinically characterized by progressive diffuse ataxia, dysarthria, hand and head tremors, chorea, and dystonia.1 The onset may occur as growth retardation primarily between the ages of 1 and 20 years. Cognitive impairment, mental retardation, peripheral axonal neuropathy, distal atrophy, superficial and deep sensory insufficiency, and hypo-/areflexia are seen in the progression of the disease along with movement disorders.Painful vision loss in Leber hereditary optic neuropathy with novel ND1 variant mimicking optic neuritis
More than 90% of Leber hereditary optic neuropathy (LHON) cases are caused by 1 of 3 primary mitochondrial DNA mutations.1 They are MT-ND4 (m.11778G>A, p.Arg340His), which accounts for ∼70% of all cases; MT-ND6 (m.14484T>C, p.Met64Val); and MT-ND1 (m.3460G>A, p.Ala52Thr) found in genes coding protein subunits of NADH dehydrogenase (complex I) of the electron transport chain, resulting in defective energy production.2 Most patients with LHON presents with sudden unilateral painless vision loss followed by fellow-eye involvement within weeks to months.Determination of the size of the stripping area using trypan blue in Descemet's stripping only
In recent years, corneal endothelial transplantation has become a standard procedure in the surgical management of Fuchs endothelial corneal dystrophy (FECD).1 Despite the recent development of effective surgical techniques, corneal endothelial transplantation is still associated with many complications, including transplant rejection, graft dysfunction, postoperative complications, and the scarcity of donor grafts.Follicular lymphoma isolated to the superior oblique muscle
A 76-year-old female presented with bilateral peripheral visual field constriction. She had a past medical history of left common iliac vein stenting secondary to compression from the iliac artery, left lower extremity deep vein thrombosis requiring angioplasty, bilateral lower extremity lipodermatosclerosis, hyperlipidemia, vitamin D deficiency, diverticulitis, and generalized anxiety disorder. Her regular medications included apixaban, clopidogrel, venlafaxine, and montelukast. She denied smoking or alcohol use.Surgical management of a recurrent hereditary benign intraepithelial dyskeratosis lesion involving a Boston keratoprosthesis
The Boston keratoprosthesis (Kpro) can provide vision in high-risk keratoplasty eyes (i.e., neovascularization, limbal stem cell deficiency [LCSD]), where normal keratoplasty invokes a high likelihood of failure. Because of increased risks of melts, keratitis, and endophthalmitis, Kpro eyes need close monitoring with close inspection of the front plate optical stem–keratoplasty junction. One disease entity in which management via Kpro has not been described previously is hereditary benign intraepithelial dyskeratosis (HBID).Double anterior chamber following deep anterior lamellar keratoplasty with endothelium-on donor tissue
Deep anterior lamellar keratoplasty (DALK) is a well-established technique for corneal transplantation because of its lower risk of postoperative graft rejection than penetrating keratoplasty.1 One possible complication of DALK is the formation of a double anterior chamber (AC). During surgery, a microperforation of the Descemet's membrane (DM) may create a channel that allows aqueous fluid to enter the host–donor interface, forming a pseudo–anterior chamber. Double ACs are typically observed in the immediate postoperative period.Acute suppurative bacterial dacryoadenitis with abscess formation in a child
Acute suppurative bacterial dacryoadenitis (ASBD) is an uncommon ophthalmic condition that is rare in the pediatric population. Rarely, ASBD may progress to the formation of a lacrimal gland abscess that, in the absence of timely and effective management, poses a risk of ophthalmic and neurologic complications. This typically involves systemic antibiotics, and particularly in paediatric cases, definitive management may involve surgical incision and drainage.Metastasis of endometrial carcinoma to the ocular adnexa
A 61-year-old female was referred by her oncologist for a rapidly enlarging, painful erythematous mass in the region of the left medial canthus, first noticed 1 month prior. She reported no change in vision, no epiphora, and no discharge from the eye. She had been using warm compresses and gentle massage to no effect. She had no past ocular history. Her past medical history was notable for metastatic endometrial carcinoma with metastases to lung and femur, for which she had completed numerous rounds of chemotherapy and radiation as well as total abdominal hysterectomy with bilateral salpingo-oophrectomy years prior.Bilateral primary squamous cell carcinoma of the conjunctiva
Squamous cell carcinomas (SCCs) of the conjunctiva are rare, with an estimated incidence of 1–2.8 per 100 000 people per year.1 SCC is the most frequently occurring malignant epithelial tumour of the conjunctiva.2 Here we present a case of a patient presenting with 2 distinct primary carcinomas of the conjunctivae over a 3-year period.
