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.
A previously healthy, 19-year-old male presented for a visit in our department at 15–20 National Ophthalmology Institute with complaints of bilateral decreased visual acuity. He reported a blunt trauma on both eyes 8 days before due to resistance band (Fig. ) used for strengths exercises at home. He went through ophthalmological examination in another department the day of the trauma. At the visit, best-corrected visual acuity (BCVA) in right eye (RE) was 20/400 and 20/1,000 in the left eye. Slit-lamp examination did not show any scleral wound, corneal wound, or traumatism of the lens. Air-puffed intraocular pressure (IOP) was 14 mm Hg in the RE and 16 mm Hg in the left eye (LE). Air-puffed IOP device was used due to the risk of unknown scleral perforation in this traumatic context. Devices were cleaned with sanitizing spray after each examination, and a time-period of 15 min was respected between each patient examination in accordance with Hygiene Department guidelines. Fundus examination showed bilateral preretinal hemorrhages not allowing further examination. B-ultrasonography revealed no evidence of retinal tears or retinal detachment. No treatment has been started. The patient could not be referred initially to a reference center due to national lockdown while COVID-19 was spreading. One week later, BCVA was below 20/200 on RE and 20/1,000 on LE. IOP was 12 mm Hg on both eyes. Fundus examination after a 7-day delay recorded inferotemporal rupture of Bruch membrane on RE and inferior diffuse preretinal hemorrhages on both eyes. Fundus autofluorescence demonstrated increased autofluorescence in traumatic pigment epitheliopathy (Fig. ). Peripheral retinal examination was normal. Spectral-domain OCT (Heidelberg Engineering Inc., Heidelberg, Germany) showed bilateral increased reflectivity, disruption of the inner/OS (IS/OS), and loss of the external limiting membrane in the macular area (Fig. ). A full-thickness thin macular hole was present only on RE. Retinal thickness was decreased below 200 μm at the sites of the lesions. We decided to introduce oral steroids therapy 40 mg a day. The patient has been notified of the poor prognosis. The 6-week follow-up revealed a BCVA at 20/80 on RE and 20/63 on LE. The fundus examination showed a slight decrease of preretinal hemorrhages on both eyes. Spectral-domain OCT (Heidelberg Engineering Inc., Heidelberg, Germany) showed a spontaneous closure of macular hole on RE, and however, outer retinal layers remained atrophic on both eyes (Fig. ). No macular hole was present on left eye. The subject had given his written informed consent for publication of its case.