Dengue fever is common in the tropics and its clinical manifestations and complications are well-known. However, dengue-related ocular complications are rare. Here we present a postpartum female who complained of bilateral central scotoma, at five days after the clinical diagnosis of dengue fever. The ocular examination was suggestive of dengue maculopathy and foveolitis. She was treated with a combination of intravenous methylprednisolone and immunoglobulin. The final visual recovery was good.
Headache can be a primary or secondary disorder. The characteristics of headache and its associated features, especially the presence of red flag signs, are important in distinguishing secondary from primary causes. Hemicrania continua is a type of primary headache disorder characterized by a continuous unilateral headache with episodes of exacerbations and association with cranial autonomic symptoms, which include several ocular symptoms. The absolute response to indomethacin remains the hallmark of this disease. We would like to report a rare case of hemicrania continua with scintillating scotoma during exacerbations apart from the typical autonomic features of conjunctival injection, ptosis, eyelid edema, and lacrimation.
Dengue infection is epidemic but ocular complications of dengue are less reported. We report a case of dengueinfected patient with disturbing ocular symptoms. He was admitted for severe dengue. Subsequently, he presented with symptoms of bilateral central scotoma with metamorphosia. Fundus examination revealed cotton wool spots and flame-shaped haemorrhages at the macula, with dull foveal light reflex. He was diagnosed with bilateral dengue maculopathy. The patient was managed conservatively with surveillance. One week later, his eye symptoms improved and were resolved six months later. Early recognition and close monitoring remains the key to successful management and interventions are rarely needed.
Altitudinal visual field defect is a rare presentation of retrochiasmal lesion especially when bilateral visual fields were affected. In fact, bilateral inferior altitudinal visual field defect (BIAVFD) usually occurred in patients who survived a gunshot injury to the occipital lobe or as a direct trauma to the brain. We report a rare case of BIAVFD secondary to occipital meningioma. A high index of suspicion enables timely investigation and diagnosis when dealing with atypical presentation of intracranial meningioma.
We report a case of myopic choroidal neovascularization that showed improvement after a single injection of ranibizumab. A 45-year-old Chinese man with high myopia presented with sudden onset painless central scotoma of his right eye of 2 weeks' duration. There was no history of trauma. His right eye vision on presentation was 6/30 which showed no improvement with pinhole. The right fundus showed myopic maculopathy at the posterior pole with subretinal hemorrhage at the inferotemporal fovea. The optic disc was tilted with inferotemporal peripapillary atrophy. There was a myopic maculopathy appearance in the macula of the left eye. Fundus fluorescein angiography revealed choroidal neovascularization at the fovea of the right eye. A diagnosis of right eye choroidal neovascularization secondary to myopic maculopathy was made. A single intravitreal injection of ranibizumab 0.05 mL was given. Ten weeks following intravitreal injection, vision had improved to 6/7.5, and repeated fundus fluorescein angiography showed absence of choroidal neovascularization. Follow-up at 6 months showed visual acuity had normalized to 6/6 with glasses, which was maintained up to 12 months following treatment. The right fundus showed no further subretinal hemorrhage with no new lesions.
Optic perineuritis (OPN) is a subtype of optic neuritis (ON) in which the inflammatory process involves meningeal sheath surrounding the optic nerve. Clinically, OPN simulates ON. However, in contrast to ON, patient with OPN shows sparing of central vision, improves dramatically with high-dose corticosteroid, are more likely to experience recurrence after stopping treatment. We report a rare case of caecocentral scotoma observed in a female with typical ON symptoms. Her magnetic resonance imaging showed features in line with OPN. She was treated with intravenous methylprednisolone 1 g/day for five days followed by slow tapering dose of oral prednisolone for one month. Her vision improved dramatically with a resolution of visual field defect. No relapses seen within two years of follow-up.
Introduction: High altitude retinopathy (HAR) is part of high altitude illness (HAI) which includes acute mountain sickness, high altitude cerebral oedema and pulmonary oedema. We present a case of bilateral HAR with right eye central scotoma during Mount Everest expedition. Case description: A 37-year-old lady presented with decreased right eye (OD) vision and central scotoma during ascending to the top of Mount Everest at 5100m. She developed respiratory symptoms with shortness of breath at the same time and warranted her a rapid descend on day eight of her excursion. Ocular examination revealed visual acuity of 6/36 OD and 6/6 left eye (OS). Both pupils were normal without relative afferent pupillary defect. Anterior segment and intraocular pressure were unremarkable. Fundus examination revealed bilateral multiple retinal haemorrhages along vascular arcades, with macula involvement in the right eye only. Otherwise there was no sign of optic disc swelling, vascular sheathing or choroidal involvement. Optical coherence tomography (OCT) of the macula showed hyperreflectivity changes on the right fovea at the level of superficial nerve fiber layer. Diagnosis of bilateral HAR was made and treated conservatively. She was also diag-nosed with HAI with acute pulmonary oedema and pneumonia by the treating physician. The retinal haemorrhages started to resolve after two weeks with full recovery of vision in ten weeks. Conclusion: With increasing popularity of mountaineering, ophthalmologists should be prepared to recognise HAR as part of HAI. Visual impairment depends on the location and extent of the lesions. HAR is self-limiting with good prognosis but can be associated with poten-tially fatal conditions of HAI e.g. pulmonary oedema in our case.
Macular branch retinal vein occlusion (BRVO), a type of retinal vein occlusion, is rarely recognised as a distinct entity. Macular BRVO has unique clinical features and different natural courses than the major BRVO. We report a case of a young patient with macular BRVO with macular oedema who was successfully treated with intravitreal ranibizumab injection. A 43 year-old Chinese man with no underlying medical illness presented with 2 weeks history of left eye painless reduced central vision which was worsening over time. On examination, his left eye visual acuity was 6/30 and Amsler chart drawing showed a lower central scotoma. Dilated fundus examination found marked flame-shaped retinal hemorrhages with cotton wool spot over the superior macular area bounded superiorly by superior arcade and macular thickening. An optical coherence tomography revealed cystoid macular oedema; and fundus fluorescein angiography showed occlusion of a small venous branch draining a superior part of macula to superior temporal venous arcade. A complete medical investigation found that he has hypertriglyceridemia and he was managed accordingly. His vision had improved to 6/6 after receiving 3 injections of intravitreal ranibizumab with no residual central scotoma and complete resolution of macular oedema.
A 21-year-old Chinese gentleman with no known medical illness, presented with a history of right painless blurring of vision with central scotoma of two weeks duration. He also had a history of multiple episodes of seizures prior to presentation. Visual acuity was 1/60 with unremarkable anterior segment findings and no relative afferent pupillary defect. Fundus examination of the right eye revealed dilated and tortuous retinal veins with multiple retinal capillary hemangiomas and sub retinal hard exudates at the macula with edema. A diagnosis of Von Hippel Lindau disease was made when a posterior fossa mass suggestive of hemangioblastoma with obstructive hydrocephalus was seen on computed tomography of the brain. Craniotomy with nodule excision was performed. The retinal capillary hemangiomas were treated with the combination of laser photocoagulation and intravitreal Ranibizumab injections. Visual acuity subsequently improved to 6/36.
A 23-year-old lady presented with both eye progressive painless blurring of vision for two weeks in 2011. Prior to that she had malar rash, hair loss, photosensitivity and bilateral leg swelling. Ocular examination showed that visual acuity on the right was 6/60 and on the left was 6/24. Both optic disc were swollen with extensive peripapillary cotton wool spot (CWS), flame shape haemorrhages, dilated and tortuous vessels with macular oedema. Systemic examination revealed blood pressure of 176/111 mmHg, malar rash and alopecia. Diagnosis of grade 4 hypertensive retinopathy secondary to SLE was made. The diagnosis was confirmed by positive ANA/ dsDNA, low C3/ C4 and renal biopsy showed lupus nephritis. She was treated with oral prednisolone, hydroxychloroquine and cyclosporin A. Throughout the monitoring for hydroxychloroquine toxicity, vision over both eyes were 6/9, but serial visual fields showed non-progressive left superior and inferior scotoma while right eye showed inferior scotoma. The intraocular pressure was normal with pink optic disc and cup disc ratio of 0.3. Optical coherence tomography (OCT) showed temporal and nasal retinal nerve fiber layer thinning bilaterally. However, macula OCT, fundus fluorescein angiography and autofluorescence were normal. The visual field defect was concluded secondary to CWS indicating microinfarction of the retinal nerve fiber secondary to previous hypertensive retinopathy. Non-progressive visual field defects may occur after the appearance of CWS in hypertensive retinopathy and it should not be overlooked when diagnosing glaucoma or hydroxychloroquine toxicity.