Photo Essays
Teaching of the lateral tarsal strip technique using a duct tape simulation
A lateral tarsal strip is a surgical procedure commonly used in oculoplastics for the repair of entropion and ectropion. A lateral tarsal strip involves correction of horizontal lid laxity with incision at the lateral canthus. Residents may have difficulties with suture placement of the tarsal strip in the periosteum. In an effort to facilitate the surgical teaching of this technique, we propose a straightforward surgical simulation to reproduce the technique. A plastic skull model, standard duct tape, surgical instruments, and suture are needed.Role of multimodal ocular imaging in Alport syndrome
A 19-year-old man with Alport syndrome presented with diminution of vision in his left eye. Slit-lamp biomicroscopy showed an early anterior lenticonus with an anterior subcapsular cataract in his right eye (Fig. 1A) and a dense anterior polar and anterior subcapsular cataract in his left eye (Fig. 1B). Fundus photography revealed central perimacular dot-and-fleck retinopathy with a dull macular reflex or lozenge in both eyes (Fig. 1C, 1D). The flecks were better visualized on red-free imaging as a ring of fine white stippling around the macula (Fig.IgG4-related orbital disease
A 67-year-old man presented with a 3-week history of diplopia and left ocular pain. Examination showed limitation of abduction of the left eye. Computed tomographic scan demonstrated a soft tissue density mass in the ethmoid sinus (yellow arrow) with extension into the left orbit and infiltration of the medial rectus muscle (Fig. 1A). Incisional biopsy revealed a dense lymphoplasmacytic infiltrate (Fig. 1B), storiform fibrosis, and obliterative phlebitis (yellow arrow, Fig. 1C). Immunohistochemistry was positive for immunoglobulin 4 (IgG4; IgG4+ cells > 30/hpf and IgG4:IgG ratio > 40%) (Fig.A practical approach to slit-lamp smartphone photography
Several approaches to smartphone anterior segment photography that involve purchasing an adapter to attach to the slit lamp have been described in the literature. Given the frequent updates in sizes and shapes of smartphones, a practical stepwise approach to capturing high-quality images without the need for an adapter is essential. First, the illumination is set to be diffuse, using the slit-lamp integrated diffuser (Fig. 1A, 1B). The camera flash is turned off, and the slit lamp is brought into focus on the anterior segment.Retinal racemose hemangioma characterization with multimodal imaging
Racemose hemangioma is an arteriovenous vascular malformation in which the retinal vessels appear abnormally dilated. The arteries are connected with the veins directly, without the interposition of a capillary network (Fig. 1A), forming a fragile vascular mass with turbulent flow that is predisposed to thrombosis phenomena. The fluorescein angiography (Fig. 1B) shows filling of the malformation without exudation. The optical coherence tomography and the optical coherence tomography-angiography en face (Figs.Assistant-controlled directional chandelier
Chandelier endoillumination has become common everyday practice for most vitreoretinal surgeons. The assistant-controlled directional chandelier is a solution to controlling, minimizing glare of, and directing the light when using a chandelier endoillumination device (Video 1, available online). With the use of readily available items within a vitreoretinal operating room setting, the Luer connector is attached to the light pipe with adhesive dressing (A). Approximately 6 mm of residual light pipe is left exposed to stop the assistant from inadvertently advancing the light pipe too deeply into the eye (B).Corneal metallic particles after cataract surgery are safe in magnetic resonance imaging
On close inspection, tiny metallic particles are visible in all corneal incisions after cataract surgery (arrows). They appear to occur after passing cannulas or other instruments through the incisions. The presence of these particles was documented prior to undergoing magnetic resonance imaging (MRI) in 3 patients (Fig. 1A–C). No adverse events occurred during the MRI, and there was no visible artifact on the MRI images (Fig. 1D, axial T2) in the plane of the incisions. These particles appear to be innocuous and do not preclude MRI studies.Commotio retinae secondary to fragmented intraorbital pellets
A 20-year-old man presented with multiple facial gunshot injuries. Visual acuities were 20/20 each eye, with full color vision and normal pupillary responses. Examination showed subconjunctival hemorrhage, mild anterior chamber inflammation, extensive commotio retinae involving the macula, and inferior retinal hemorrhages (Fig. 1A). Computer tomography (Figs. 1B–D) showed orbital emphysema and multiple fragmented left extraconal and intraconal pellets—one in close proximity to the posterior aspect of globe, adjacent to the optic nerve.Retinal vasculitis after intravitreal injection of brolucizumab
An 82-year-old man with age-related macular degeneration presented with painful vision loss in the right eye 42 days after his third brolucizumab injection (Beovu, Novartis, Basel, Switzerland). Visual acuity was light perception (baseline, 20/150). Examination revealed moderate to severe vitritis, arterial sheathing, diffuse arterial and venous narrowing, and perivenular hemorrhages (Fig. 1A,1B). Fluorescein angiography demonstrated extensive arterial and venous filling defects with peripheral nonperfusion (Fig.Retinal crystalline lesions in pseudoxanthoma elasticum
An 11-year-old healthy boy was evaluated for incidental retinal crystalline lesions. Visual acuity was 20/20 in both eyes. Fundus examination of the right (A) and left (B) eyes demonstrated multiple crystalline bodies (blue arrows) scattered throughout the midperipheral and peripheral retina, a peau d'orange pattern of retinal pigment epithelial (RPE), alterations in the temporal retina (white arrow), and angioid streaks (yellow arrow) around the optic nerve on fundus autofluorescence imaging (C).Management of a large metal intraocular foreign body
A 49-year-old man had been seen 1 month prior by a general ophthalmologist for a healing corneal abrasion. On examination, there was a dense vitreous hemorrhage and a subtle iris transillumination defect suspicious for an occult intraocular foreign body (IOFB; Fig. 1A). A computed tomography scan confirmed an IOFB that extended from the inferior posterior iris to the posterior pole (Fig. 1B). Intraoperatively, the traumatic cataract was removed along with the ruptured capsular bag (Video 1, available online).Management of a dislocated 3-piece intraocular lens with an iris prosthesis in situ
A 33-year-old man with a past injury of the left eye involving iris loss and choroidal rupture in 2002, presented with 1-month history of spontaneous blurry vision. On examination he had a dislocated 3-piece Ophtec (Netherlands) intraocular lens (IOL) in the vitreous with an iris prosthesis (Human Optics, Germany) dislocation sutured at 9:00 o'clock and poorly attached at 3:00 o'clock (Supplementary Video 1). The already kinked IOL was cut and explanted (A), and a secondary IOL inserted and fixated to the sclera behind the iris prosthesis using a Yamane technique (B).Secondary vasoproliferative tumor in adult-onset Coats disease
A 20-year-old woman noted a 1-month history of floaters in her left eye. Ultra-widefield multicolor imaging and fluorescein angiography (Figure A, B) showed classic findings of Coats disease (telangiectasia, exudation, subretinal fluid, and peripheral nonperfusion) and an additional yellow-red dome-shaped mass of 3 mm thickness that corresponded to a secondary vasoproliferative tumor encircled by gravitating lipid exudation. Coats disease usually occurs in children but can affect older patients.Third nerve palsy due to influenza A infection
A previously healthy 38-year-old woman presented with new onset left ptosis and diplopia. Two days prior, she developed nasal congestion, cough, fever, and myalgias. Examination revealed left ptosis and a limitation of elevation, depression, and adduction of the left eye (50% of normal). Pupils were equal sizes and reactive to light, and the remainder of the neurological examination was normal. Magnetic resonance imaging with gadolinium revealed mild enhancement (Fig. 1A) and an increased size and T2 signal (Fig.Traumatic retinal detachment and macular hole due to exercise resistance band injury
A 20-year-old sustained a resistance band injury after adopting a home-workout routine during pandemic gym closures. He presented with an inferior retinal detachment due to a large, jagged, equatorial retinal tear; a full-thickness macular hole; and a shallow superior retinal dialysis Figure I. He underwent vitrectomy, and because of the extensive commotio, there was inadequate laser uptake. With silicone oil tamponade, laser was completed postoperatively Figure II. Following silicone oil removal, the macular hole is closed Figure II and the vision has improved from 20/400 to 20/60.Shield-shaped cataract in severe atopic dermatitis
A 32-year-old woman presented with a progressive decrease of vision in right eye and bilateral and severe skin eczema. The best-corrected visual acuity was 20/40 in the right eye and 20/20 in the left eye. The patient was previously diagnosed with atopic dermatitis. On slit-lamp examination, a shield-shaped anterior capsular cataract was observed, as well as an important anterior blepharitis. Although posterior subcapsular cataracts are more frequent in atopic dermatitis, shield-shaped cataracts are more specific to this disease.Full thickness posterior globe perforation managed with laser photocoagulation
A 22-year-old male patient was urgently referred following an all-terrain vehicle (ATV) accident. On presentation, the patient had extensive bilateral periorbital fractures. Dilated fundus exam of the right eye demonstrated a full-thickness chorioretinal and scleral perforation infero-nasal to the optic disc with mild vitreous hemorrhage (Fig. 1A). Laser photocoagulation was performed around the perforation site. Three months after the injury, the patient had visual acuity of 20/20 in his right eye with complete resolution of the vitreous hemorrhage.Lens capsule rupture in a nonaccidental trauma
Here we present an image of the lens capsule rupture of the left eye of a 6-month-old female believed to be a victim of nonaccidental trauma. Grossly, the lens of the left eye appears irregular in shape compared with the lens of the right eye), showing this is unlikely artifactual or due to tissue processing. The image demonstrates a capsule break with distinct scrolling pattern at the edge. There are numerous hemorrhages of varying sizes in all retinal layers with rare blood cells seen in the vitreous cavity, as well as the optic nerve hemorrhage, not pictured.Corneal myxoma after pressure washer injury
A 71-year-old man presented with an enlarging left eye lesion, 6 years after pressure-washer injury. Examination showed a lobulated, gelatinous lesion with associated cornea neovascularization, obscuring the fundus (A). The fellow eye was normal. High-frequency ultrasound confirmed that the lesion was anterior to the corneal stroma (B). Lesion excision resulted in improved vision, but with residual cornea edema (C). Histopathology demonstrated loose mesenchymal tissue with stellate fibroblasts and scattered thin-walled vascular structures, consistent with corneal myxoma (hematoxylin-and-eosin stain, original magnification, × 200) (D).Bilateral retinal detachment imaged by Mirante color photography and retro mode illumination
A highly myopic 45-year-old man with bilateral rhegmatogenous retinal detachments was imaged using Mirante Scanning Laser Ophthalmoscope (SLO) device by Nidek (Nidek Co, Ltd., Gamagori, Nidek). (A, B) The widefield color fundus photographs show the full extent of the retinal detachment in both eyes and peripheral retinal breaks. A large horseshoe tear and a smaller tear are observed superotemporally (A), whereas a single break is observed superotemporally (B). The prominent corrugations/retinal folds associated with the detachment are clearly evident.Knobloch syndrome: a rare cause of paediatric retinal detachment
Knobloch syndrome is a very rare disease characterized by the following triad: occipital defect, high myopia, and retinal detachment. It is caused by COL18A mutation, inherited in an autosomal recessive pattern.Rare case of anterior lenticonus
A 17-year-old girl presented with defective vision in both eyes. On ocular examination, she showed anterior lenticonus in both eyes with normal fundus and an “oil droplet reflex” on retroillumination (Fig. A, B). Lenticonus is characterized by conical protrusion of the anterior or posterior lens surface. Posterior lenticonus is more common than anterior and is usually unilateral. Anterior lenticonus is often bilateral and is usually associated with Alport syndrome. Alport syndrome results in renal failure, which can be avoided by early diagnosis and prompt referral.Creating aerosolized droplets in phacoemulsification
A wetlab was set up using porcine eyes, an artificial anterior chamber maintainer, and an Alcon Infiniti phacoemulsification system (Fort Worth, TX; Fig. A). Colouring dye was placed in the irrigation fluid for easy identification of droplets on a white paper surface surrounding the eye. During simulated phacoemulsification, droplet/aerosol production occurred when the irrigation ports were in the incision, but not when they were entirely within the anterior chamber. A similar study, using cadaveric eyes and a 2.2 mm phacoemulsification sleeve, also found that no droplet/aerosol was produced when instruments were held entirely within the anterior chamber.Diffuse spontaneous intraretinal hemorrhages in familial retinal arteriolar tortuosity
A 51-year-old healthy woman presented with a 3-month history of bilateral scattered scotomas. There was no history of anticoagulant use, Valsalva, or trauma. Family history was noted for episodic retinal hemorrhages of unknown cause in her mother.Exotropic bilateral internuclear ophthalmoplegia following a superior cerebellar artery aneurysm clipping
A 62-year-old man developed binocular diplopia during hospitalization for an upper-gastrointestinal bleed 1 month after clipping of a superior cerebellar artery aneurysm. Gradient echo showed punctate microhemorrhage at the level of left inferior colliculus (Fig. 1). Motility examination revealed primary gaze left hypertropia (presumed skew deviation) with bilateral exotropia, adduction deficits, and dissociated horizontal abducting nystagmus and downbeat component with intact convergence, consistent with an exotropic bilateral internuclear ophthalmoplegia (EBINO; see Video).
