A 48-year-old male obtained a whiplash neck injury and a fracture of the articulate processes of the 7th neck vertebrae from a traffic accident. Two days later, he reported blurred vision in the left eye (LE). Although the best corrected visual acuity (BCVA) was 20/25, Amsler grid test was positive. There was preretinal paramacular hemorrhage on fundus examination. OCT, OCTA, visual field (VF) examination, fluorescein angiography (FA), and multifocal electroretinogram (mfERG) were performed. To analyze foveal structure and thickness, we utilized a swept-source (SS)-OCT and OCTA system (Triton, Topcon, Tokyo, Japan). The central retinal thickness (CRT) was defined as the average thickness in the central circle area. For OCTA, 4.5 × 4.5 × 4.5 mm3 macular cubes were obtained. En face images of the retinal vasculature were created from the superficial capillary layer (SCL) and deep capillary layer (DCL), based on the automated layer segmentation. The FAZ area was defined as the area inside the central border of the capillary network and was manually delineated on the inner border using the standard software and then calculated automatically. VF was measured in macular program (M program, Octopus 900, Haag-Streit, USA) and mfERG and FA (Canon) were performed accordingly. OCT showed no fluid but a slight disruption of the outer plexiform layer (OPL), outer nuclear layer (ONL), retinal pigment epithelial (RPE) layer, and photoreceptors (PR) with hyper-reflectivity of the ellipsoid zone (EZ) and interdigitation zone (IZ) and remained unchanged throughout the 1-year follow-up (Fig. ). CRT was 241 and 257 μm for the LE and RE, respectively. VF showed fixed central scotoma (Fig. ). mfERG was unremarkable. FA revealed late paramacular hyperfluorescence in both eyes. OCTA showed an enlarged FAZ area in the SCL of 334,402 μm2 in the LE as compared to 253,521 μm2 in the RE, as well as in the DCL, measuring 814,944 μm2 in the LE as compared to 311,858 μm2 in the RE, respectively (Fig. ).
A 43-year-old married Syrian woman presented at the age of 40 with distortion of central vision in the right eye. Choroidal dystrophy was suspected in Damascus (Syria) ( and ). Rheumatology and infectious workup was negative (syphilis, tuberculosis, anti-double-stranded DNA, anti-single-stranded DNA, rheumatoid factor). CNV was also detected in the macular area in Dubai (United Arab Emirates) and intravitreal injections were advised. She subsequently received three monthly intravitreal ranibizumab injections in Barcelona (Spain) (). Past ocular history revealed myopia of 2.5 D as per patient recollection. She had undergone bilateral refractive surgery (excimer laser 5 years ago followed by laser in situ keratomileusis [LASIK] 3 years ago). Medical history was negative. There was a strong family history of myopia and no parental consanguinity. Fifteen months after initial right eye involvement, the patient expressed the same symptoms in the left eye, such as seeing broken lines and asymmetric faces. She was advised to undergo treatment for CNV in the macular region. She received one injection in Beirut (Lebanon), and subsequently, three monthly injections in Dubai to the left eye. She reported further worsening of vision after each injection. Consultation in London (UK) revealed a best-corrected visual acuity of 20/80 in the right eye and 20/30 in the left eye. Dilated fundoscopy revealed bilateral areas of vertically linear atrophy, more extensive in the right eye, without subretinal fluid or hemorrhage by optical coherence tomography. Fundus autofluorescence imaging revealed areas of reduced autofluorescence corresponding to these areas of atrophy. The reported clinical impression then was myopic chorioretinal degeneration versus lacquer crack-associated myopic degeneration. She was advised to have regular checkup without intravitreal injections as long as the macula stays dry. The patient was frustrated because of both inability to pinpoint a definite diagnosis and gradual decline in vision bilaterally. Nine months later, she initially presented to our clinic with 20/200 visual acuity. Fundoscopy revealed definite widening of the vertical macular choroidal rupture bilaterally (). Stippled changes in the retinal pigment epithelium were observed. Peau d’orange appearance was not present. The patient was emmetropic without keratoconus on corneal topography. Axial length measurement with the IOL Master (Carl Zeiss Meditec AG, Jena, Germany) was 27.35 mm in the right eye and 27.31 mm in the left eye. Keratometry readings were 38.6 D in the right eye and 38.2 D in the left eye. The skin of the neck had tiny pinkish papules suspicious for early goose flesh (). Two separate dermatology consultations and skin biopsies did not favor the diagnosis of pseudoxanthoma elasticum. Even further widening of the choroidal rupture occurred 9 months after presentation. Our working diagnosis was lacquer crack from high myopia (without pseudoxanthoma elasticum) () possibly initiated by LASIK and exacerbated by ocular rubbing and intravitreal injections (). The patient was instructed to avoid ocular rubbing, head-down position, and intravitreal injection (unless an exudative component was present) and to have prior paracentesis before any future intravitreal injections.