David Doobin, MD, PhD
Massachusetts Eye and Ear
The Atlantic Coast Retina Club 2023 meeting continued for a second day on February 2nd with a great day of cases. Session E featured a variety of cases that covered infectious, inflammatory, and degenerative conditions.
It began with Dr. David Wu from Mass Eye and Ear describing an 84-year-old who presented with serous choroidal detachments with an adjacent retinal detachment. Exam was notable for pigment in the vitreous, an inferior operculum, but no breaks or holes. The patient underwent surgical drainage of the choroidals and vitrectomy, during which the causative break was found. Of note, she had a pigment epithelial detachment and early AMD in this eye, and those changes improved after vitrectomy. Audience members commented that in certain cases like this, oral steroids can be prescribed for a few days to lessen the serous choroidal detachments, and then the break can be found if the detachment is indeed rhegmatogenous and not serous.
Dr. William Mieler from University of Illinois, Chicago/Illinois Eye and Ear presented a case of a 77-year-old man with an asymptomatic, peripheral, raised fibrotic mass, found incidentally. Of note, the patient completed treatment for recently diagnosed testicular large cell lymphoma. Dr. Mieler did not recommend biopsy of this mass, but the patient sought a second opinion, had a vitrectomy with an excisional biopsy with the outside ophthalmologist, but this only revealed fibrous tissue. The patient did well after this biopsy, but later came back with symptomatic vision loss in his other eye. He was found to have creamy white choroidal lesions and chorioretinal changes in both eyes, MRI brain with changes, and a brain biopsy confirmed the diagnosis of lymphoma. The patient has undergone several rounds of treatment, and though the eyes have improved, his disease has continued to advance. Dr. Mieler asked the audience if he should have biopsied earlier, and Dr. Carol Shields advised against this since it would likely have still shown “fibrous cells”, but both her and Dr. Jose Pulido pointed out that MYD88 PCR can still be run on fibrous tissue and should still be positive.
Next, Dr. Shilpa Desai of Tufts University discussed a 99-year-old hypertensive woman who was referred for intraretinal hemorrhages of the left eye. Exam was notable for hand motion vision in the left eye, which had preretinal, intraretinal, and subretinal hemorrhage, all coming from a ruptured retinal artery microaneurysm. The patient also had count fingers vision in her ‘good eye’, with subretinal fluid on exam and OCT. Careful inspection of the macula cube revealed a very small full thickness macular hole. It was believed that subretinal fluid was due to macular hole-related retinal detachment. The patient deferred treatment for both conditions. Dr. Desai also used this presentation to generously educate the entire retina community about “doomscrolling” and its benefits, which was very well received.
Dr. Danny Mammo of Cole Eye Institute admirably presented a retina case without a single fundus photo or OCT. It was a 71-year-old female who recently had a conjunctival excisional biopsy with cryotherapy and was referred weeks later for a large, white anterior chamber mass. During the initial biopsy she was given Subtenon’s Kenalog, and when she was referred, she was on oral steroids and had count fingers vision. There was concern for endophthalmitis, and an anterior chamber tap in clinic failed to remove any part of the white lesion. The patient was brought to the OR, a vitreous cutter was used to remove the lesion in the anterior chamber, and purulence was noted around the STK injection site. Cultures were positive for Nocardia. Dr. Mammo pointed out that 80% of Nocardia endophthalmitis presented with a large white lesion in the anterior chamber, such as this case, and that these bacteria are often resistant to vancomycin but susceptible to amikacin.
Finally, Dr. Dean Eliott from Mass Eye and Ear discussed a 65-year-old male with a history of BRVO complicated by macular edema, receiving aflibercept injections, who came in for a routine injection. Prior to receiving his injection, he was noted to have disc edema in his other eye, and further history revealed that he had been experiencing worsening leg weakness, dizziness, numbness, and shortness of breath. He was sent to the emergency room and a brain MRI revealed pachymeningeal enhancement. He was admitted to internal medicine and further workup found bone lesions, splenomegaly, and lymphadenopathy. A lymph node biopsy showed monoclonal plasma cells and given the constellation of findings the patient was diagnosed with POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Myeloma Proteins, and Skin Changes). Notably POEMS is associated with elevated systemic VEGF, but this patient had been receiving aflibercept for macular edema and had low systemic VEGF levels. Aflibercept was held for 3 weeks, and systemic VEGF levels soared, clinching the diagnosis of POEMS. The patient was treated systemically and improved, but he still requires aflibercept in the initial eye for the BRVO related macular edema. There was a lively discussion among the audience, with Dr. Robert Avery explaining that intraocular aflibercept can suppress plasma VEGF levels systemically for several days, consistent with the data Dr. Eliott presented.