Digital Journal of Ophthalmology

Thank you to our 2023 reviewers

Ankoor Shah — 2024-01-22

The editors of the Digital Journal of Ophthalmology thank our expert peer reviewers for 2023. All of these individuals have volunteered their time to contribute to our goal of providing a highquality free-access ophthalmic journal.

Isolated cavernous venous malformation of the eyelid

Khushdeep Abhaypal — 2024-01-15

Cavernous hemangioma, currently known as “cavernous venous malformation,” is a common, benign, non-infiltrative, slowly progressive vascular malformation of the orbit presenting in adults. We report the case of a 9-year-old girl who presented with a painless palpable mass over the right upper eyelid of 7 years’ duration. A computed tomography scan of the orbits revealed a heterogeneously enhancing, well-circumscribed mass in the right upper eyelid with no orbital extension. A transcutaneous excisional biopsy with histopathology disclosed cavernous venous malformation. The majority of cavernous venous malformations are intraconal and present in the fourth to fifth decade of life.

Juvenile ocular myasthenia gravis: a report of two cases

Ryan Gabbard — 2024-02-02

We report 2 cases of pediatric ocular myasthenia gravis. The first case was a 7-year-old girl who presented with bilateral ophthalmoplegia and ptosis that correlated with the onset of upper respiratory symptoms. Neuroimaging and acetylcholine receptor antibody testing were unremarkable. The ice pack test was positive. Symptoms greatly improved with pyridostigmine, with full resolution of ophthalmoplegia achieved by 8-month follow-up. The second case was a 4-year-old girl who presented emergently with ptosis and bilateral ophthalmoplegia. Acetylcholine receptor antibodies testing was positive. The patient was started on pyridostigmine and intravenous immunoglobulin and is scheduled to follow-up with pediatric ophthalmology in the outpatient setting.

Lethal mycotic pseudoaneurysm presenting as isolated sixth nerve palsy

Rasna Bhanuman — 2024-03-20

Pseudoaneurysm of the internal carotid artery caused by skull base osteomyelitis (SBO) is a lethal condition seen in immunocompromised patients, predominantly those with diabetes mellitus. Cranial nerve involvement is a common complication and generally indicates a poor prognosis. We report the case of a 62-year-old diabetic patient who presented with isolated sixth cranial nerve palsy. She had uncontrolled blood sugar levels and high erythrocyte sedimentation rate, and she suffered from pyelonephritis. Neuroimaging detected SBO with multiple secondary mycotic pseudoaneurysms prominent at the petrocavernous junction. Ischemia is the most common etiology for an isolated abducens nerve palsy, but in certain cases neuroimaging is warranted to prevent life-threatening complications. This case highlights the importance and urgency of identifying and managing such conditions.

Natural course of hemorrhagic sub–internal limiting membrane detachment in association with retinal artery macroaneurysm

Denizcan Özizmirliler — 2024-01-19

A 60-year-old man with hypertension was evaluated at our departmental clinic at Dokuz Eylül University for sudden vision loss in his left eye. Color fundus images (A-B) and spectral domain optical coherence tomography sections (C-D) taken 3 months apart show the presentation and evolution of hemorrhagic sub–internal limiting membrane detachment (red arrows) associated with retinal and subretinal hemorrhages due to retinal arterial macroaneurym (black arrows). Observation for resolution was recommended.

Cataract in coloboma: ectopic lens lying in a retinochoroidal coloboma

Maria Madeira — 2024-02-11

A 79-year-old-man presented for routine ophthalmological examination. He had a history of untreated amblyopia in the right eye and bilateral cataracts. His uncorrected visual acuity was light perception in the right eye and 20/160 in the left eye. Slit-lamp examination revealed typical inferonasal iris colobomas, apparent aphakia in the right eye, and cataract in the left eye (A). Funduscopic examination (B) complemented by B-scan ultrasonography of the right eye (C) revealed a luxated lens (arrow) lodged in a retinochoroidal coloboma (arrowheads), in association with proliferative vitreoretinopathy. Coloboma results from incomplete closure of the embryonic fissure. The affected structure depends on whether that failure is anterior (iris coloboma), posterior (retinochoroidal coloboma) or both, such as in this case. Involvement of the zonules or ciliary body in anterior coloboma predisposes to ectopia lentis because there is insufficient lens support.

Post-traumatic phacotopic glaucoma

Priyanka Golhait — 1997-02-16

A 62-year-old man presented at Guru Nanak Eye Centre, New Delhi, with unilateral painless diminution of vision in his left eye following accidental blunt trauma by elbow. On examination, visual acuity in the eye was 6/60 (logMAR 1.00), with brisk pupillary reflex. Anterior segment evaluation showed a clear cornea with shallow anterior chamber (Van Herick grade1) and angle closure in all quadrants on gonioscopy. Dilated evaluation revealed 6 clock hours of anterior and temporally subluxated cataractous lens, from 6 to 12 o’clock, with loss of zonules in the subluxated area. There was no gross phacodonesis, no inflammatory reaction nor vitreous in anterior chamber, and intraocular pressure was 26 mm Hg in that eye. Posterior segment findings were unremarkable, with a healthy neuroretinal rim. The right eye had no significant abnormality. Anterior segment optical coherence tomography showed an anteriorly subluxated cataractous lens with peripheral iridocorneal contact. Gonioscopy showed closed inferior, superior, temporal, and nasal angles. A diagnosis of phacotopic glaucoma was made and a prophylactic peripheral iridotomy with frequency doubled Nd:YAG laser was performed to prevent pupillary block. The patient was scheduled for intracapsular cataract extraction with scleral-fixated intraocular lens under the cover of ocular hypotensive medications. Following surgery, the patient had an acceptable visual outcome of 6/12 (logMAR 0.30), with normal intraocular pressures at the end of 6 months’ follow-up.

Unmasking silicone oil in the anterior chamber

Sahiti Puttagunta — 2024-03-27

A 77-year-old man with aphakia presented at L V Prasad Eye Institute with sudden pain and high intraocular pressure. Examination revealed silicone oil in the anterior chamber (AC). He had preciously undergone vitreoretinal surgery for rhegmatogenous retinal detachment, with use of a silicone oil tamponade. He also had an inferior peripheral iridectomy (PI). Typically, silicone oil remains in the posterior chamber of aphakic eyes in a spherical form and does not enter the AC. However, in the presence of pupillary block, aqueous accumulates in the lower part of the posterior chamber, increasing pressure and forcing the silicone oil through the pupil into the AC, potentially obstructing outflow from the angles. This condition is often clinically missed because of a deep AC and iridectomy appearing as patent on retroillumination, lacking typical signs of pupillary block, such as iris bombe and shallow AC. The presence of oil in the AC is identified by stagnant cells that would otherwise circulate with aqueous convection currents. The shining reflex on the iris due to oil (A, black arrow) and a thin fibrin layer on the peripheral iridectomy, causing the blockage, helped in identifying the oil in this case. Reopening the iridectomy with Nd:Yag laser allowed aqueous to flow into the AC, with silicone oil retreating into the posterior chamber (B-C), gradually evacuating the silicone oil from the anterior chamber (D).

Improving polymerase chain reaction diagnostic rates for herpes simplex keratitis: results of a pilot study

Alice L. Milligan — 2024-02-12

Background
Laboratory confirmation is crucial for diagnosis and management of herpes simplex virus (HSV) keratitis. However, the sensitivity of polymerase chain reaction (PCR) in keratitis is low (25%) compared with that of mucocutaneous disease (75%). We developed an educational intervention aimed at improving the diagnostic yield of PCR.

Methods
The medical records of keratitis cases seen at the emergency department of a London tertiary ophthalmic referral hospital over two distinct periods, before and after an educational program on swab technique, were reviewed retrospectively.

Results
A total of 252 HSV cases were included. Increases in the laboratory-confirmed diagnosis of HSV-1 were observed, in both first presentations (11.1%-57.7%) and recurrent cases (20%-57.6%). The rate of positive HSV-1 PCR in eyes with an epithelial defect increased from 19% pre-intervention to 62% post intervention. Notably, 3% were positive for varicella zoster virus DNA, and there was a single case of Acanthamoeba keratitis.

Conclusion
Our results suggest that, with proper swabbing technique, PCR may be more sensitive than previously reported.

Pilot study of musculoskeletal pain in ophthalmologists following participation in a fifteen-minute online Iyengar yoga program

Michelle E. Akler, MD — 2024-03-06

Purpose
To evaluate the prevalence of musculoskeletal (MSK) complaints in ophthalmologists and to assess whether participation in an online Iyengar yoga video program improves the baseline pain scores and awareness of proper posture in the clinic and operating room.
Methods
Ophthalmologists were recruited from online professional forums for this nonrandomized, prospective study. A pre-intervention survey, including demographics, office and procedure volumes, wellness activities, and baseline MSK pain scores, was completed. A fifteen-minute instructional video focusing on simple yoga poses for the neck, shoulder, and lower back created by one of the authors, who is both an ophthalmologist and a certified Iyengar yoga teacher, was provided to participants to complete three times weekly for a total of 4 weeks. A post-intervention survey collecting MSK pain scores and information about ergonomics and compliance was completed.
Results
Fifty ophthalmologists completed the pre-intervention survey, of whom 49 (98%) reported at least 1 episode of MSK discomfort in the preceding year. Of those, discomfort was cervical in 36 (72%), in the shoulder(s) in 15 (29%), thoracic spinal in 23 (46%), lumbar spinal in 23 (46%), and centered in the wrist, hand, or finger in 22 (44%). Of the 50 ophthalmologists, 22 submitted the post-intervention surveys. The post-intervention pain scores were decreased compared to baseline for cervical spine (P < 0.01), shoulder (P < 0.01), thoracic spine (P < 0.01), lumbar spine (P < 0.01) and wrist, hand, or finger (P < 0.01). 20 respondents (91%) reported improved awareness of their posture in the clinic and operating room, and 19 (86%) felt that this awareness would decrease their MSK symptoms.
Conclusions
Among our small group of survey respondents, a fifteen-minute Iyengar yoga video program specifically designed for ophthalmologists reduced MSK pain and improving awareness of proper ergonomics for practicing ophthalmologists.