Alex Shaer, BS
Wills Eye Hospital/Thomas Jefferson University Hospitals, Philadelphia, PA
The medical retinal potpourri session was moderated by Jay Chhablani, MD, and contained an assortment of diverse medical topics, conditions, and treatments, all given together to provide a broad overview of interesting, varied cases. Five cases were presented by: Allen Chiang, MD; K Bailey Freund, MD; Benjamin J. Kim, MD, and Sonia Mehta, MD.
First to present was Dr. Allen Chiang from Wills Eye Hospital, who discussed a case of a 50-year-old patient complaining of greenish blurred spots in their right eye. Fundus photography and fundus autofluorescence demonstrated chronic retinal pigment epithelium changes bilaterally, including an inferior gravitational tract of fluid from the macula, concerning for chronic central serous chorioretinopathy (CSCR). The patient was treated with photodynamic therapy but continued to have visual complaints and was ultimately referred to endocrinology for testing. Endocrine evaluation revealed normal cortisol levels with low ACTH, and an adrenal incidentaloma on abdominal MRI. This raised the question of subclinical Cushing syndrome, and the panel discussed whether patients with chronic CSCR should be more routinely referred for endocrine workup. The panel discussed how this may yield a diagnosis in select cases but may also result in potentially extensive negative evaluations.
Next, Dr. K. Bailey Freund from VRMNY, presented an imaging case of a myopic patient with schisis. Fundus photography and fundus autofluorescence showed non-specific dark without pressure and white without pressure findings, widefield fluorescein angiography revealed subtle hyperfluorescence corresponding to these dark without pressure lesions. This was suggestive of retinal neovascularization with no appreciable inflammation or retinal vascular occlusion. Dr. Freund also highlighted bilateral loss of hyperreflectivity in the regions of dark without pressure, corresponding to ellipsoid zone loss. The etiology of these retinal vascular changes and ellipsoid zone loss in myopic schisis was discussed. Potential explanations included optical effects related to vitreoretinal traction affecting the optical properties of the interdigitation zone as well as changes in choroidal melanin.
Dr. Benjamin J. Kim from Scheie Eye Institute then discussed an 83-year-old with neovascular age-related macular degeneration previously treated with anti-VEGF injections who presented to him as a new patient. Fundus photography demonstrated macular drusen bilaterally, while OCT revealed a cyst-like structure in the left eye with fluid between the nasal macula and optic disc. OCT optic nerve showed fluid diving below the retina near the optic disc, consistent with either pit-like maculopathy or an occult optic pit. The patient was managed conservatively with observation and discontinuation of anti-VEGF therapy. They had stable findings on follow-up. Lastly, Dr. Kim noted the presence of peripapillary choroidal neovascularization, which may have been incidental or helped to support an occult optic pit etiology, as prior literature has described abnormal leaking vessels associated with optic pits.
Last to speak was Dr. Sonia Mehta from Wills Eye Hospital. She presented a patient with breast and endometrial cancer with pancytopenia complaining of decreased vision in the right eye. The exam showed vitritis, vitreous hemorrhage, and chorioretinal whiting with elevation. The patient was treated with antibiotics two weeks prior without improvement. Given the initial lack of response, broad empiric therapy was initiated, including antifungal, anti-toxoplasmosis, and antiviral treatment. During this, an extensive systemic workup including blood cultures, PCR testing, echocardiogram, and other systemic imaging was undertaken. However, no causative organism or source was identified. The diagnosis was presumed endogenous fungal endophthalmitis because subsequent imaging following continued antifungal therapy demonstrated improvement in intraocular inflammation as well as the chorioretinal lesions. This case highlighted the diagnostic challenge of fungal infections, as blood cultures are only positive in 9-45% of cases and vitreous cultures in 25-55%.
