Linnet Rodriguez, MD
Wills Eye Hospital
Herein we review a fantastic Session D on Saturday of the Atlantic Coast Retina Club, moderated by David M. Wu, MD and Jasmine Francis, MD.
The first case was presented by Matthew R. Starr from Mayo Clinic. He presented an interesting case of a 67-year-old male with progressive bilateral peripheral vision loss for two years. The patient had a past medical history of resected hypopharyngeal squamous cell carcinoma and a kidney lesion that was being followed with serial CT scans. The fundus exam was pertinent for peripheral RPE changes with normal optic nerve disc and vessels. OCT showed outer retina changes and FAF showed stippled hyperautofluorescence and hyporautofluorescence in the perifoveal region. Patient underwent extensive ophthalmic imaging with IVFA, HVF and ERG. He also underwent laboratory testing for infectious and inflammatory etiologies, autoimmune retinopathy panel, and whole genome sequencing, which were all unremarkable. The enolase antibody levels, however, were abnormal. Patient underwent partial nephrectomy and renal biopsy revealed renal cell carcinoma. The patient was treated with plasma exchanges followed by intravenous immune globulin (IVIG). After treatment, OCT showed reconstitution of the outer retina layers. The presentation ended with the final diagnosis of presumed visual changes due to paraneoplastic syndrome in the setting of renal cell carcinoma.
The next presenter was John W. Thompson from Retina Specialists of Baltimore. He discussed a brief case of an 89-year-old male with past ocular history of myopia who presented with floaters in the left eye. The fundus exam was pertinent for a vitreous free-floating, marble like lesion with a small tail, located in the inferior midperiphery of the left eye. B scan showed moderate reflectivity with 2×4 mm in size. The diagnosis was a vitreous cyst. Dr. Thompson commented on this being an unusual presentation because usually vitreous cysts are typically optically empty, and overall an unusual phenomenon for retina specialists to encounter.
Andre J. Witkin from Tufts Medical Center presented an excellent case of a right orbital cavernous hemangioma in a 26-year-old female that was initially referred for macula stria of the right eye. Initial OCT showed subtle inner retina folds with no significant effect on visual acuity. Observation, therefore, was recommended. The patient returned three years later with complaints of decreased vision and eyelid swelling. The exam was pertinent for decreased visual acuity and a RAPD. Fundus photos showed more folds and Hertel exophthalmometer showed proptosis of the right eye. The patient subsequently underwent evaluation with brain MRI that demonstrated a right intraconal encapsulated mass. The mass was removed by the oculoplastic service and pathology confirmed the lesion to be a cavernous hemangioma.
Xuejing Chen from Boston University presented an outstanding and unique case of Vogt-Koyanagi-Harada disease. Patient was a 42-year-old female from Trinidad who initially presented with unilateral painless vision loss in the left eye. Visual acuity was HM with a left RAPD. The exam was pertinent for rare vitreous cells and choroidal detachment in the periphery of the left eye. OCT showed a lumpy bumpy configuration with loss of the choroid architecture and basilar detachments. Patient was also noted to have short axial length with thickened sclera of the left eye. Extensive laboratory testing was performed as well as brain MRI which were unremarkable. She was diagnosed with VKH and started on oral Prednisone as well as topical steroids. This regimen was later transitioned to IMT. The presenter concluded the case by mentioning that, most likely, this presentation was unilateral given the shorter axial length and thickened scleral of the affected eye in comparison to the fellow eye.
The session concluded with James P. Dunn from Wills Eye Hospital who presented a case of retina sarcoid granuloma. This was a 20-yeard-old male who presented with blurred vision in the right eye for 3 weeks. The fundus exam showed vascular sheathing of both eyes and a vascularized pre and intraretinal lesion at the level of the optic nerve head. Patient underwent extensive ophthalmic imaging, laboratory testing and chest imaging revealing an elevated ACE with hilar adenopathy. Patient was started on a course of oral Prednisone and given sub–Tenon’s Kenalog injection with no significant improvement in the lesion. The session concluded with an audience discussion regarding other options for treatment including intravitreal Ozurdex. The final question was if the audience would consider direct injection of the lesion and the audience responded no.