Corneal collagen cross-linking has become the preferred modality of treatment for corneal ectasia since its inception in late 1990s. Numerous studies have demonstrated the safety and efficacy of the conventional protocol. Our understanding of the cross-linking process is ever evolving, with its wide implications in the form of accelerated and pulsed protocols. Newer advancements in technology include various riboflavin formulations and the ability to deliver higher fluence protocols with customised irradiation patterns. A greater degree of customisation is likely the path forward, which will aim at achieving refractive improvements along with disease stability. The use of cross-linking for myopic correction is another avenue under exploration. Combination of half fluence cross-linking with refractive correction for high errors to prevent post LASIK regression is gaining interest. This review aims to highlight the various advancements in the cross-linking technology and its clinical applications.

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Conjunctival biopsies constitute a fairly large number of cases in a typical busy ophthalmic pathology practice. They range from a single biopsy through multiple mapping biopsies to assess the extent of a particular pathological process. Like most anatomical sites, the conjunctiva is subject to a very wide range of pathological processes. This article will cover key, commonly encountered nonneoplastic and neoplastic entities. Where relevant, sections will include recommendations on how best to submit specimens to the ophthalmic pathology laboratory and the relevance of up-to-date molecular techniques.

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Purpose: Indian children belong to a diverse socioeconomic strata with retinopathy of prematurity (ROP) developing in mature, higher birth weight babies as well. The purpose of our study is to analyze the long-term status of refractive errors and its relationship with ocular biometry in children with ROP who were laser treated at a tertiary center in North India. Methods: Cross sectional study. Children (<16 years) enrolled from January 2014 to December 2014 with a history of laser treatment for ROP and examined for refractive and biometric status. Results: Thirty-six children presenting to us at the mean age of 7.37 ± 3.07 years (6–15 years) were included. Mean spherical equivalent (SE) was −4.05 D ± 5.10. 75% were myopic, with high astigmatism in 31%. Higher lens thickness (P = 0.03) and higher SE (P = 0.002) at 1 year postnatal age were predictors of larger SE. 79.4% achieved a favorable functional outcome (visual acuity ≥20/40). 5.88% achieved unsatisfactory outcome (<20/200) despite having a favorable structural outcome. Conclusion: There are a substantial number of children who develop myopia and high astigmatism while undergoing laser treatment for ROP. We found myopia in our cohort to be lenticular and greater axial length contributing to the development of high myopia. An initial large refractive error predicts the future development of myopia in these children. Nearly 6% of patients with good structural outcome have unexplained subnormal vision. Our threshold for prescribing glasses in these children should be low.

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Purpose: The purpose of this study was to determine the effectiveness of preventing eye injury with the use of safety eyewear in agriculture workers. Methods: A sample group of 575 agricultural workers (Group A) engaged in harvesting paddy were provided with goggles with side covers. Following harvesting, a questionnaire-based survey was carried out to determine the frequency of their eye injuries. Workers with goggles were asked about the duration for which they used the goggles and also list barriers or difficulties with the same. The frequency of eye injuries in this group was compared with another group of agriculture workers (Group B) who did not use any safety eyewear. Results: The frequency of eye injuries in Group A was 4 (0.7%) and Group B was 61 (11.3%) which was highly significant (P = 0.0001). The relative risk calculated was 0.06 (95% confidence interval: 0.02–0.2). Agricultural workers in Group A had 94% less risk of ocular trauma compared to those in Group B. Injuries in both groups were caused by parts of the paddy plant. A significant number (76.2%) of workers used the goggles all or most of the time during work. Impaired vision when wearing goggles was the most frequent barrier reported by the workers. Other barriers were discomfort, shyness, forgetfulness, apathy, slowing of work pace, awkward appearance, and breakages. Conclusion: Safety eyewear conferred significant protection against work-related eye injuries in agriculture. Although safety eyewear was widely adopted by the workers, barriers reported by them will need to be addressed to make such programs more effective.

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Purpose: Resections and plications tighten recti although the latter are less traumatic, potentially reversible, quicker, and vascularity preserving. To compare inflammation, scarring, and alignment in horizontal strabismus, operated uniocularly by either resections or plications (with recessions): recession and resection (R&R) or recession and plication (R&P) groups. This was a prospective, patient and assessor blind, randomized trial. Methods: All consenting strabismus patients qualifying for the first-time uniocular horizontal rectus surgeries underwent detailed ocular examination and were randomized into standard R&R or R&P groups. For the latter, we folded the tendon-muscle strap the desired amount using 6-0 polyglactin, suturing it to its insertion, entailing no disinsertion. We compared the groups for inflammatory grades (individually for congestion, chemosis, discharge, foreign-body sensation, and drop intolerance and aggregated to a total inflammatory score (TIS), scar visibility (SV) at 1 m, and successful alignment (≤10 prism diopter of orthotropia). We used Mann–Whitney and Fisher's exact tests, with significance at P ≤ 0.05. Results: We randomized 40 patients: 22 to R&R and 18 to R&P. The groups were comparable in age, strabismus onset and duration, and strabismus amount. The inflammatory scores, both individual and TIS, were comparable at all time-points: all P > 0.05. SV proportions were not significantly different: 16/22 in R&R versus 9/18 in R&P; P = 0.19. There were no significant differences in success rates: 14/22 versus 10/18, P = 0.74. Conclusion: Our study shows that plication is similarly effective as resection, when combined with recession in horizontal strabismus, and should be resorted to more frequently.

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Purpose: To compare the outcomes of intraoperative wavefront aberrometry versus optical biometry alone for intraocular lens (IOL) power calculation in eyes undergoing cataract surgery with monofocal IOL implantation. Methods: Preoperative data were obtained with the IOLMaster. Intraoperative aphakic measurements and IOL power calculations were obtained in some patients with the optiwave refractive analysis (ORA) system. Analysis was performed to determine the accuracy of monofocal IOL power prediction and postoperative manifest refraction at 1 month of the ORA versus IOLMaster. Results: Two hundred and ninety-five eyes reviewed, 61 had only preoperative IOLMaster measurements and 234 had both IOLMaster and ORA measurements. Of these 234 eyes, 6 were excluded, 107 had the same recommended IOL power by ORA and IOLMaster. Sixty-four percent of these eyes were within ±0.5D. 95 eyes had IOL power implantation based on ORA instead of IOLMaster. Seventy percent of these eyes were within ±0.5D of target refraction. 26 eyes had IOL power chosen based on IOLMaster predictions instead of ORA. Sixty-five percent were within ±0.5D. In the group with IOLMaster without ORA measurements, 80% of eyes were within ±0.5D of target refraction. The absolute error was statistically smaller in those eyes where the ORA and IOLMaster recommended the same IOL power based on preoperative target refraction compared to instances in which IOL selection was based on ORA or IOLMaster alone. Neither prediction errors were statistically different between the ORA and IOLMaster alone. Conclusion: Intraoperative wavefront aberrometry with the ORA system provides postoperative refractive results comparable to conventional biometry with the IOLMaster for monofocal IOL selection.

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Purpose: To analyze the current practice patterns of Indian pediatric ophthalmologists in the management of lens anomalies. This study was conducted in a tertiary eye care hospital and involved an online questionnaire survey for practicing pediatric ophthalmologists in India. Methods: A questionnaire was devised by the authors, which included the various options available for the management of lens anomalies in children. The questionnaire was sent to each of them using an online portal. Commercial software (Stata ver. 13.1; StataCorp, College Station, TX, USA) was used for statistical analysis. Results: In unilateral cataracts in children aged <6 months, 85.42% of surgeons did not prefer to insert an intraocular lens (IOL). In the age group of 6–12 months, almost half of them preferred to insert an IOL. In the age group of 12–24 months and >24 months, 92.63% and 88.54%, respectively, preferred to insert an IOL. In bilateral cataracts, in children aged <6 months, 91.84% of surgeons did not prefer to insert an IOL, whereas in the age group of 6–12 months, 69.39% did not prefer to insert an IOL. In the age group of 12–24 months and >24 months, 80.61% and 90.82%, respectively, preferred to insert an IOL. Seventy-four percent of surgeons preferred to use a single-piece hydrophobic acrylic IOL. Conclusion: The management of lens anomalies by pediatric ophthalmologists in India varies with laterality and appears to be comparable to that followed worldwide.

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Purpose: The purpose of this study is to measure intraocular pressure (IOP) and evaluate the correlation between IOP and midnight plasma cortisol (MPC) level in patients with Cushing's disease (CD) and other endogenous Cushing's syndrome (ECS). Methods: This is a cross-sectional study from a single center including newly diagnosed patients with CD or ECS. All patients underwent detailed ophthalmological evaluation. IOP was measured by Goldmann applanation tonometry in the morning and evening on two consecutive days. MPC value was obtained for each patient. The data were compared using paired and unpaired t-test, Mann–Whitney U-test, and Spearman's rank correlation coefficient. Results: Among 32 patients, 22 were CD (68.75%) and 10 patients were other ECS (31.25%). A total of 25 patients (78.12%) in our study group had normal IOP (<22 mmHg), and seven patients (21.88%) had increased IOP (≥22 mmHg). The percentage of patients with normal IOP was found to be significantly higher compared to percentage of patients with high IOP (P = 0.001) using one-sample Chi-square test. Mean MPC value was 468.6 ± 388.3 nmol/L in patients having IOP ≥22 mmHg and 658.5 ± 584 nmol/L in those with IOP <22 mmHg from both CD and ECS groups, but the difference was not statistically significant. No correlation was found between IOP and MPC (Spearman's rank correlation rho = −0.16 [P = 0.38]). Conclusion: In CD and ECS patients, IOP elevation is an uncommon feature, and high IOP in either group does not correlate with MPC level.

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Perivascular epithelioid cell tumor (PEComa) is a rare neoplasm considered to arise from myomelanocytic cell lineage. The uterus is reportedly the most common site to be involved. Orbital PEComa is extremely rare with only two cases reported till date. A 5-year-old male presented with a right medial orbital mass for the last 6 months. The patient was diagnosed with alveolar soft part sarcoma elsewhere. Magnetic resonance imaging features were suggestive of lymphangioma with bleeding. The excision biopsy revealed multiple tumor cells comprising epithelioid cells with clear cytoplasm, along with nuclear atypia and mitosis. Immunohistochemistry was positive for HMB-45, smooth muscle actin, vimentin, and CD-34. It was negative for cytokeratin, S-100, and synaptophysin, which clinched the diagnosis of malignant orbital PEComa. Neoadjuvant chemotherapy was administered. There was no recurrence at 24 months of follow-up. At present, there is no consensus on management protocol for malignant PEComa. Complete surgical excision with chemotherapy appears to offer the best prognosis.

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Purpose: The purpose of this study is to compare the refractive error outcomes in the eyes of premature babies with retinopathy of prematurity (ROP) who underwent laser plus lens-sparing vitrectomy (LSV) in one eye and laser alone in the fellow eye. Methods: This is a retrospective study. Fourteen babies with Stage 4A of ROP or worse who underwent laser plus LSV in one eye (Group 1) and laser alone in the fellow eye (Group 2) were followed at 2 months, 6 months, 1 year, one and a half year, and 2 years. The main outcome variable studied was cycloplegic refraction at the baseline and follow-up visits. The change in spherical and cylindrical power at each visit was compared in Groups 1 and 2. The changes in spherical equivalent in subgroups were analyzed. Results: Mean gestational age at birth was 29.43 ± 2.10 weeks (range 26–32 weeks). Mean chronological age at the time of surgery was 4.11 ± 3.00 months (range 2–10 months). Mean postmenstrual age was 45.86 ± 12.13 weeks (range 39–75 weeks). Mean birth weight was 1340.71 ± 361.59 g (range 860–1980 g). All the babies in both groups had progressive myopia till 2 years follow-up; laser group had less myopia than LSV group till 1 year, thereafter, there was no difference in median till 2-year follow-up. The mean ± standard deviation of spherical equivalent in LSV versus laser group was: −4.36 ± 5.52 versus −3.21 ± 4.59 at 2 months; −5.09 ± 5.82 versus −4.04 ± 4.68 at 6 months; −7.14 ± 5.36 versus −5.36 ± 5.09 at 1 year; and −7.47 ± 1.38 versus −6.41 ± 1.91 at 2 years. Spherical equivalent difference across the visits did not differ significantly between Groups 1 and Group 2 in children whose birth weight was <1500 g (P = 0.247) and those who had more than 1500 g (P = 0.748), in those with gestational age between 20 and 30 weeks (P = 0.215) compared to those >30 weeks (P = 0.602). Conclusion: No difference in the progression of myopia was noted in eyes that underwent additional LSV following laser photocoagulation in one eye and laser alone in the fellow eye.

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Keratosis follicularis (Darier's disease) is a rare (1 in 30,000–100,000) genetic autosomal-dominant predominantly dermatological disorder characterized by hyperkeratosis and acantholysis due to a defective calcium transport in the cells. Ocular findings, if present, are very rare in this condition. Here, we are reporting a case of keratosis follicularis (Darier's disease) with ocular manifestations that have not been reported so far to the best of our knowledge.

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We present a rare case of corneal ulcer caused by a species of a coelomycetes fungus, Chaetomium strumarium. This fungal genus is a rare causative agent of keratomycosis, with only a handful of cases reported. The clinical presentation, investigative techniques, and preliminary management of our patient are reported. The cases reported in global literature are also summarized in a tabular form in the discussion.

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Purpose: We sought to document the difference in the vitreoretinal configuration of Stage 4 retinopathy of prematurity (ROP) in photocoagulated and treatment naive eyes undergoing vitrectomy and to correlate it with surgical complexity. Methods: Consecutive eyes posted for vitrectomy with Stage 4 ROP were documented preoperatively using a RetCam for the presence of peripheral traction (PT), presence of central traction just outside the arcades, and presence of traction extending to the lens. A note was made of the following intraoperative events: lensectomy, intraoperative bleeding, and iatrogenic breaks. Wilcoxon rank-sum test was used for analysis. Results: From a total of 46 eyes, 16 and 30 eyes were from the treated and treatment naive group, respectively. More eyes in the treated group had central (P < 0.0001) and lenticular traction (P = 0.022). More eyes in the untreated group had PT (P < 0.0001). A significant number of eyes without photocoagulation needed lensectomy (P = 0.042), and no difference in intraoperative bleeding (P = 0.94) was demonstrable. Iatrogenic retinotomy occurred in three eyes, all naive. Notably, age at surgery was more in the untreated group (P = 0.00008). Conclusion: Vasoproliferative activity in all retinopathies occurs at the junction of the ischemic and nonischemic retina. In the natural course of ROP, this takes place peripherally, at the ridge. In photocoagulated eyes, this junction is displaced posteriorly due to peripheral ablation. Treated eyes manifested with posterior proliferative changes and were more amenable to lens-sparing vitrectomy. Naive eyes were older when they underwent surgery to relieve PT with greater chances of lensectomy and iatrogenic breaks.

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Alport syndrome is a rare hereditary disease that is associated with retinal abnormalities such as dot-and-fleck retinopathy and temporal macular thinning. The main pathophysiological process of Alport syndrome is loss of the collagen network in the basement membrane. However, the alterations in each retinal layer have not been fully evaluated. In the case presented here, we evaluated the retina of a patient with Alport syndrome using en face optical coherence tomography (OCT). The findings suggested that the primary alterations occur in the internal limiting membrane and the retinal pigment epithelium basement membrane which is a part of the Bruch's membrane. The adjacent retinal layers are damaged subsequently. In conclusion, en face OCT could be useful in evaluating retinal abnormalities and understanding their underlying pathophysiology in Alport syndrome.

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Dermatofibrosarcoma protuberans is a soft tissue sarcoma that is dermal in origin. The incidence is <0.1% of all malignancies and 1% of soft tissue sarcoma. Most commonly, it involves trunk (62%) followed by extremities (25%) and head and neck (13%). It is a slow growing tumor with locally aggressive behavior. Here, a 50-year-old female diagnosed with orbital dermatofibrosarcoma developed extra-axial component in right frontal region even on chemotherapy. Hence, the bad prognostic factors are yet to be established in dermatofibrosarcoma protuberans.

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A 51-year-old immunocompetent male with a history of Fuchs' endothelial dystrophy and immature cataract who underwent Descemet's stripping automated endothelial keratoplasty with intraocular lens implantation in both eyes presented with redness and defective vision of 1-day duration in his left eye. Slit lamp examination revealed coarse superficial punctate lesions with graft edema. He was diagnosed with acute graft rejection and treated with topical steroids. Two days later, symptoms worsened in his left eye with the involvement of his right eye showing a similar clinical picture. An infectious etiology was suspected and in vivo confocal microscopy ordered, which revealed hyperreflective dots, highly suggestive of microsporidial spores. The patient was prescribed topical fluconazole 0.3% in both eyes. This unique presentation of bilateral graft edema following microsporidial keratoconjunctivitis in postgraft patients requires a high index of suspicion as it can be easily be mistaken for and mismanaged as acute graft rejection.

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Purpose: Corneal collagen cross-linking (CXL) is a treatment strategy used in keratoconic eyes. Evaluation of long-term changes of higher-order aberrations (HOAs) after CXL is useful in understanding the efficacy of this procedure in improving optical, refractive, and visual acuity. This study aims to investigate the long-term effect of CXL on ocular HOA in patients with progressive keratoconus (KC). Methods: Using an OPD-Scan II aberrometer, ocular HOAs measurements of 56 eyes of 56 patients that underwent CXL was evaluated at the baseline, 1, 2, and 4 years after the procedure. All OPD-Scan measurements were decomposed into Zernike coefficients from 3^rd to 6^th order. Results: The results revealed that except for a few parameters, most of the aberration parameters continuously decreased during the study. In the 4-year postoperative period, a statistically significant improvement in all HOA parameters except 5^th order Zernike polynomials (Z₅¹, Z₅⁻¹, Z₅³, Z₅⁻³, Z₅⁵, and Z₅⁻⁵) was observed. All the values significantly decreased compared to the preoperative measurements (P < 0.05). The mean ± standard deviation (SD) root mean square of the 3^rd, 4^th, and the 5^th order as well as coma, coma like, and total HOA parameters were significantly decreased compared to both preoperative and previous visits (P < 0.001). There were significant correlations between preoperative measurements of HOAs parameters with best-corrected visual acuity (BCVA) including Z₃¹, Z₃⁻¹, Z₄⁰, Z₅¹, and Z₄². Moreover, all the HOAs parameters in 4 years after the CXL were significantly correlated with BCVA (P < 0.05). Conclusion: CXL is effective in improving HOA parameters in eyes with progressive KC during a long-term follow-up.

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An upper lid eccrine hidrocystoma presenting as early childhood progressive ptosis is very rare. We present a 9-year-old female child with droopy right upper lid since birth and progressive increase in symptoms. She had right upper lid ptosis (marginal reflex distance 1 of −1 mm) with fair levator function (8 mm) and abnormal cystic change on the conjunctival side. Computerized tomography imaging delineated the well-defined cystic lesion with homogeneous cavity with no contrast enhancement. Following the cyst excision, a giant eccrine hidrocystoma measuring 25 mm × 15 mm was removed, the largest reported in pediatric eyes. The case demonstrates the possibility of giant lid eccrine hidrocystomas presenting as progressive ptosis at a pediatric age and the need for early surgical intervention to prevent amblyopia.

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Purpose: The aim of this study was to evaluate risk factors in patients with macular telangiectasia (MacTel) 2A in an Asian population. This was a hospital-based case–control study. Methods: We reviewed the case records of patients in our hospital, diagnosed as MacTel 2A over a 3-year period from April 2011 to March 2014. Controls were selected from patients seen in the hospital at the same time for visual defects after matching for age and sex. A multivariate logistic regression model was constructed using the variables that showed a statistically significant association (P < 0.05) with MacTel 2A in the univariate analysis. Results: The mean age of the patients with MacTel 2A was 58.63 years. A majority (76; 73.8%) of the patients were female. Of the patients with MacTel 2A, 61 (59.2%) patients had diabetes mellitus, and 50 (48.5%) revealed hypertension. Multivariate logistic regression analysis revealed the presence of diabetes mellitus to be the risk factor with the highest odds ratio (OR) of 5.7 followed by hypertension with an OR of 2.6. Binary logistic regression showed hypermetropia to have a greater risk factor compared to emmetropia, OR 2.64. Conclusion: Our case–control study revealed that MacTel 2A is significantly associated with systemic diseases. Diabetes mellitus was found to have the strongest association with MacTel 2A, showing a high OR of 5.7. Systemic hypertension followed by an OR of 2.6. Compared to emmetropia, hypermetropia was significantly associated with MacTel 2A. There could be a genetic link between the two. Determining risk factors draws us close to the goal of identifying the etiopathogenesis of MacTel 2A.

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Myxomas are rare neoplasms of mesenchymal origin. Cases of conjunctival, corneal, and orbital myxomas have been reported in the literature; however, to the best of our knowledge, there is no report of a lacrimal gland myxoma. We report a case of an orbital myxoma involving the lacrimal gland and its management.

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Case report of a 70-year-old male who developed full thickness macular hole (MH) following vitrectomy for vitreomacular traction syndrome. The further intervention was deferred due to the unwillingness of the patient for the second surgery. Periodic follow up of the patient, revealed improvement in visual acuity with the closure of the MH after 28 months.

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We describe a case of a 65-year old man diagnosed with retinal vasoproliferative tumour secondary to posterior uveitis. The fluorescein angiography shows an interesting meteor-like leak emanating from the tumour and rising towards the superior retina in the later frames of the angiogram. Pictorially, we call it the “Retinal Meteor” and also describe the possible mechanism for this pattern of leakage.

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We report a case of 43-year-old male, presented with sudden onset binocular diplopia on lateral gazes. Ocular examination showed features of ipsilateral one-and-a-half syndrome. Comprehensive systemic work in conjunction with magnetic resonance imaging of the brain illustrated irregular mixed solid and cystic lesions in the brainstem, possibly indicative of brain metastases. Further imaging revealed hidden renal cell carcinoma as a primary neoplasm, which led to secondary manifestations.

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