Thyroid eye disease (TED) characterizes by inflammation and remodeling of orbital tissues. Although the majority of pediatric TED is mild, some children present progressive and severe disease. The approach to severe disease in this group of patients, especially when noncortico-responsive, is challenging. The purpose of this work was to describe the effective use of tocilizumab as second-line therapy in steroid-resistant pediatric TED. A 13-year-old female with a history of Graves’ disease presented with right eye proptosis for at least 8 months associated with mild pain on eye movements and ocular surface complaints. The ophthalmologic evaluation revealed Hertel exophthalmometry readings of 22 mm on the right eye (OD) and 19 mm on the left (OS). The remaining ophthalmic examination was unremarkable. Intravenous methylprednisolone pulses of 500 mg were initiated without any improvement after 4 treatments. Following multidisciplinary team discussion, therapy was switched to monthly tocilizumab injections at 4 mg/kg. Significant reduction of proptosis and resolution of pain and ocular surface complaints were noted immediately after the treatment switch. Exophthalmometry readings after the end of treatment that included 4 tocilizumab injections were 20 mm on OD and 19 mm on OS. No side effects were reported during the entire follow-up. Six months after treatment cessation, the patient remains stable, without any signs of orbitopathy relapse and no ophthalmologic complaints. This is the second case report showing the effectiveness of tocilizumab in pediatric TED and the first one showing its efficacy when steroids fail. Our results support the potential safety and efficacy of this immunosuppressor in children with TED.

Retained intraocular foreign body is a known complication of ophthalmic surgery. The presence of intraocular cotton fibers after ophthalmic surgery is well-documented in different procedures including cataract and vitreoretinal surgeries. This report describes a case of retained cotton fiber after implantable collamer lens (ICL) implantation. This report describes a case of a 23-year-old female who was diagnosed with high myopia and mild astigmatism. The patient was selected to undergo ICL implantation in her right eye. The postoperative examination was done a few hours after the procedure, and a cotton fiber was incidentally found to be attached to the posterior surface of the ICL without causing visual disturbances or any other abnormal findings. This patient was followed up closely within the 2 postoperative weeks, and a 1-year follow-up did not reveal any change in the cotton fiber place or position, nor was there any other complication. In conclusion, cotton fibers are typically inert and usually do not lead to major complications. The decision of whether to surgically remove these fibers or not should only be made after weighing the benefits against the risks of such intervention. Recurrent inflammatory reactions or iridocyclitis related to the presence of cotton fibers could validate surgical intervention; however, the presence of cotton fibers solely does not necessitate early surgical removal.

Extensive macular atrophy with pseudodrusen (EMAP) is a relatively newly proposed clinical entity that was first reported in 2009. Although no definitive diagnostic criteria have been defined, characteristic findings can distinguish it from other diseases, especially dry age-related macular dystrophy (AMD). Herein, we present the case of a patient with EMAP who underwent a comprehensive ophthalmic examination and whole-exome sequencing (WES). A 72-year-old Japanese man complained of progressive visual impairment in his right eye and nyctalopia. Ophthalmic examination revealed that the best-corrected visual acuity (BCVA) in decimal units was 0.08 on the right and 0.8 on the left. Fundoscopy and fundus autofluorescence (FAF) revealed well-demarcated symmetrical macular atrophy, with a vertical axis larger than the horizontal axis, which reached the vascular arcade inferiorly and exceeded it superiorly. Pseudodrusen were widespread throughout the retina in both eyes. Paving-stone degeneration was not observed in the extreme periphery of either eye. Seven months later, his left BCVA decreased to 0.3 without major changes on multimodal imaging. Based on the above findings, we diagnosed EMAP. Wide-field optical coherence tomography angiography (OCTA) showed no significant changes in the retinal vessels, but the density of choroidal vessels was reduced in the degenerated areas. We thought that this finding suggests that EMAP originates between the deep retina and choroid. WES did not reveal any candidate mutations in known pathogenic genes. To the best of our knowledge, this is the first report of a Japanese patient with EMAP, and no data for analysis of wide-field OCTA or equatorial OCT images of EMAP cases have been found in previous reports. EMAP is not well recognized in Asia and may be incorrectly diagnosed as dry-type AMD. EMAP should be included in the differential diagnosis of dry AMD, and this may lead to more Asians being diagnosed with EMAP in the future.

Central serous chorioretinopathy (CSCR) is a retinal disease that may be complicated by the development of serous retinal pigment epithelial detachment (PED). The exact molecular mechanisms of CSCR have remained uncertain as well as there is no effective medical therapy. Herein, we describe a case of a 43-year-old male suffering from chronic CSCR with PED and visual acuity reduction (20/40) that showed improvement in visual acuity (20/25) and metamorphopsia 2 weeks after daily intake of 20 mg sildenafil tablets. Optical coherence tomography (OCT) scan showed resolution of PED with residual degeneration of the photoreceptor inner and outer segment layer and retinal pigmented epithelium. The patient continued treatment with sildenafil 20 mg for 2 months. Six months after the discontinuation of therapy, visual acuity was maintained, with absence of PED at OCT. Our case supports the hypothesis that phosphodiesterase type 5 (PDE-5) inhibitors may be an alternative in the treatment of patients with CSCR, alone or combined with other medications.

The purpose of our article was to describe a simple but effective surgical technique performed on a patient with an extrusion of part of the body of a PAUL drainage implant for glaucoma. We present the case of a patient with refractory glaucoma and a history of multiple ocular interventions. A PAUL shunt was implanted and in the early postoperative period the patient presented extrusion of part of the implant body. An excessive scarring tissue at the lateral rectus muscle tendon hampered the placement of the lateral wing under the muscle; therefore, we decided to trim a part of it and suture the implant body to the sclera. The surgical technique that satisfactorily resolved the complication is described and shown in a video. This is the first time that such complication is described with the PAUL implant. We suggest that the intrinsic characteristics of the implant, mainly the dimensions, material, and thickness, made it possible for a potentially serious complication such as that described to be solved in a relatively simple and nontraumatic way for the eye.

Choroidal osteoma is a rare clinical entity of unknown etiology. It is a benign ossifying tumor characterized by mature bone replacing choroid. It typically affects young females, unilaterally. Vision loss occurs mainly due to photoreceptor degeneration secondary to decalcification and/or development of choroidal neovascularization, especially if located near the macular area. We present a case of an old woman with bilateral choroidal osteomas identified incidentally. An 84-year-old Caucasian woman who was asymptomatic, without clinical features suggestive of choroidal osteoma, was referred to our hospital for a follow-up visit. On the fundus examination, both eyes showed a suspected lesion. B-scan ultrasound demonstrated bilateral highly reflective calcified lesions within the choroid, with an evident cone of shadow, suggestive of choroidal osteoma. Further investigations have performed to confirm the diagnosis. Although the literature reports a more common one-sidedness and typical manifestation of choroidal osteoma in the teenage years, our case report refers to bilateral choroidal osteomas in an elderly woman.

Optical coherence tomographic angiography (OCTA) has emerged as a rapid, noninvasive imaging modality to visualize the vascular networks in the retina and choroid. Here, we report the clinical findings in a case of primary vasoproliferative retinal tumor (VPRT) observed by the wide-field swept-source OCTA. A 74-year-old male patient with central vision loss and metamorphopsia in his left eye was referred to our hospital. At the first visit, the best-corrected visual acuity was 20/20 OD and 20/40 OS. Fundus examination revealed the presence of the epiretinal membrane and inferotemporal reddish retinal tumor in the left eye. Fluorescein angiography and indocyanine green angiography (ICGA) showed leaky characteristics and sharply defined structure of vessels in the retinal tumor, respectively. The patient was diagnosed with the VPRT with secondary epiretinal membrane and underwent pars plana vitrectomy with internal limiting membrane peeling, retinal photocoagulation, and triple freeze and thaw procedure using cryopexy. Whereas wide-field swept-source OCTA preoperatively depicted the flow signals as distinctive vascular structures similar to ICGA, the tumor color turned out to be ischemic white, and the flow signals detected by wide-field OCTA disappeared after the surgery, indicating that the freezing effect of transscleral cryopexy sufficiently reached the surface of the tumor. In sum, wide-field swept-source OCTA is a useful imaging modality that can be noninvasively and repetitively performed to determine the treatment effect in cases of peripheral retinal tumors such as VPRT.

The objective of this report was to describe a case of total traumatic iridodialysis in the context of blunt trauma with an orbital-floor fracture. A 76-year-old female presented post-fall with right-eye blunt trauma. She underwent canthotomy and cantholysis due to concern of orbital compartment syndrome in a regional hospital with emergency physicians clearing dark tissue near the lateral canthus at the time of canthotomy cantholysis. She had a traumatic expulsive iridodialysis with 360° loss of iris through the previous phacoemulsification wound in the clear cornea. The patient also had an orbital-floor fracture, which together with internal decompression through the previous phacoemulsification wound possibly prevented further damage to intraocular structures. There was good visual recovery. Herein, we propose that the combination of the orbital-floor fracture in tandem with the reopening of the previous phaco wound served as a decompressing mechanism to prevent further intraocular injury above that of total iridodialysis.

We report a case of a 26-year-old male patient with an incidental finding of a flesh-colored tumor with few vellus hairs on its surface, located on the fornix and the tarsal conjunctiva of the left lower eyelid. Histology of the biopsy showed a choristoma consisting of abundant vellus hairs, sebaceous glands, and sparse lacrimal gland tissue. Recognition of conjunctival vellus hairs is significant and raises the suspected diagnosis of choristoma, which can be confirmed by a small sample biopsy. A complete excision is unnecessary and possible surgical complications can be prevented. Choristomas of the tarsal conjunctiva are very rare and, to our knowledge, this is the first histological documentation of a choristoma containing vellus hair located on the tarsal conjunctiva. In addition, we review the histopathological findings of choristomas and their differential diagnoses.

A 52-year-old man with a history of facioscapulohumeral dystrophy (FSHD) and hypertension presented with decreased vision in his left eye (OS) of several weeks’ duration. The best-corrected visual acuity was 1.0 in both eyes (OU), with fundus soft exudates in the right eye (OD) and exudative maculopathy OS. Optical coherence tomography (OCT) showed macular edema and hard exudates OS, and OCT angiography (OCTA) showed nonperfusion areas and arterial tortuosity OU and a capillary aneurysm OS. After photocoagulation of the nonperfusion areas OU and intravitreal injection of aflibercept OS, the macular edema OS decreased and subjective symptoms improved. However, the nonperfusion area OS was enlarged on OCTA. We report the OCTA findings before and after antivascular endothelial growth factor treatment in a patient with FSHD.