Kranias diagnostic challenges in retinal diseases 06 20 14

DIAGNOSTIC CHALLENGES IN DIAGNOSTIC CHALLENGES IN

RETINAL DISEASESRETINAL DISEASES

GEORGE KRANIAS, M.D.GEORGE KRANIAS, M.D.

Vitreoretinal Summer SchoolVitreoretinal Summer School

June 21, 2014June 21, 2014

OCULAR MANIFESTATIONS AS AN OCULAR MANIFESTATIONS AS AN

INITIAL SIGN OF SYSTEMIC DISEASEINITIAL SIGN OF SYSTEMIC DISEASE

BRIEF OVERVIEW OF 5 CASE HISTORIESBRIEF OVERVIEW OF 5 CASE HISTORIES

PATIENT HISTORYPATIENT HISTORY

PH: 43 yo WF c/o sudden onset of blurred PH: 43 yo WF c/o sudden onset of blurred vision OS x1 day.vision OS x1 day.

PMH: Arthritis and multiple allergiesPMH: Arthritis and multiple allergiesEXAM: VA OD 20/30EXAM: VA OD 20/30

OS 20/400 OS 20/400 IOP OD 18 mm HgIOP OD 18 mm Hg

OS 18 mm HgOS 18 mm Hg BP 138/76 mm HgBP 138/76 mm Hg

LABORATORY FINDINGSLABORATORY FINDINGS

HGB: 6.5 LOWHGB: 6.5 LOW

HCT: 19.0 LOWHCT: 19.0 LOW

ANA: (+)ANA: (+)

SLE antibodiesSLE antibodies

NL 12.0-15.0NL 12.0-15.0

NL 35-42%NL 35-42%

TREATMENT COURSETREATMENT COURSE

BLOOD TRANSFUSIONBLOOD TRANSFUSION

PLAQUENIL RXPLAQUENIL RX

SYSTEMIC LUPUS ERYTHEMATOSUSSYSTEMIC LUPUS ERYTHEMATOSUS

Autoimmune inflammatory diseaseAutoimmune inflammatory diseaseMultiple organ involvementMultiple organ involvementPolyarthritisPolyarthritisSkin lesionsSkin lesionsRenal diseaseRenal diseasePericarditisPericarditisHepatosplenomegalyHepatosplenomegalyAnemiaAnemiaNeurological disorderNeurological disorder


OCULAR FINDINGSOCULAR FINDINGS::

Sjogren’s syndromeSjogren’s syndrome

ScleritisScleritis

RetinopathyRetinopathy

a. Retinal hemorrhagesa. Retinal hemorrhages

b. Cotton wool spotsb. Cotton wool spots

c. Retinal artery occlusionc. Retinal artery occlusion

d. Retinal vein occlusiond. Retinal vein occlusion


PH: 69yr. W/M c/o increased difficulty PH: 69yr. W/M c/o increased difficulty reading X1 moreading X1 mo

PMH: type II DM X12 yr, hypertension, PMH: type II DM X12 yr, hypertension, prostate and testicular CAprostate and testicular CA

EXAM: VA OD 20/200 phniEXAM: VA OD 20/200 phni

VA OS 20/200 phniVA OS 20/200 phni

BP 130/70 mm HgBP 130/70 mm Hg

LABORATORYLABORATORY

INCREASED SERUM INCREASED SERUM VISCOSITY 11.1VISCOSITY 11.1

HEMATOCRIT 15HEMATOCRIT 15

IgM PROTEIN 11,000IgM PROTEIN 11,000

NORMAL=2.0NORMAL=2.0

NORMAL=38-45NORMAL=38-45


CHEMOTHERAPY AGENTSCHEMOTHERAPY AGENTS

WALDENSTROM’S MACROGLOBULINEMIAWALDENSTROM’S MACROGLOBULINEMIA

LYMPHOPROLIFERATIVE DISORDER LYMPHOPROLIFERATIVE DISORDER

HIGH INTRAVASCULAR CONCENTRATION OF HIGH INTRAVASCULAR CONCENTRATION OF ABNORMAL MONOCLONAL IgM PROTEINABNORMAL MONOCLONAL IgM PROTEIN

INCREASED BLOOD VISCOSITYINCREASED BLOOD VISCOSITY

INCREASED INTRAVASCULAR VOLUMEINCREASED INTRAVASCULAR VOLUME

RETINOPATHY IN 50% OF CASESRETINOPATHY IN 50% OF CASES


CC: 27 yo WF c/o decreased VA x1 CC: 27 yo WF c/o decreased VA x1 week, fatigue and not feeling well. week, fatigue and not feeling well.

PMH: Unremarkable.PMH: Unremarkable.

EXAM: VA OD CF @ 5 ft.EXAM: VA OD CF @ 5 ft.

OS 20/60OS 20/60


WBC: 19.8 HIGHWBC: 19.8 HIGH

RBC: 1.13 LOWRBC: 1.13 LOW

HGB: 4.4 CRITICALHGB: 4.4 CRITICAL

HCT: 12.8 CRITICALHCT: 12.8 CRITICAL

PLT: 14.0 CRITICALPLT: 14.0 CRITICAL

NL 5.0-10.0 (X1000)NL 5.0-10.0 (X1000)

NL 4.2-5.4 (X10^6)NL 4.2-5.4 (X10^6)

NL 12.0-16.0NL 12.0-16.0

NL 36-46%NL 36-46%

NL 150-450 (X1000)NL 150-450 (X1000)


CHEMOTHERAPY AGENTSCHEMOTHERAPY AGENTS

PATIENT HISTORY

CC: 25 yo WF c/o “brown spot” CC: 25 yo WF c/o “brown spot” centrally x2 weeks. Had similar centrally x2 weeks. Had similar episode 2 mo ago, attributed to episode 2 mo ago, attributed to

optic neuritisoptic neuritis

PMH: UnremarkablePMH: Unremarkable

EXAM: VA OD CF @ 5 ft.EXAM: VA OD CF @ 5 ft.

OS 20/100OS 20/100


WBC: 14.2WBC: 14.2

RBC: 2.72RBC: 2.72

HGB: 9.1HGB: 9.1

HCT: 26.5HCT: 26.5

BLASTS 81BLASTS 81


CC: CC: 54 yo dermatologist developed 54 yo dermatologist developed scotoma OS while flying at 33,000 scotoma OS while flying at 33,000 feet. feet.

PMH: Unremarkable.PMH: Unremarkable.

EXAM: VA OD 20/60EXAM: VA OD 20/60

OS 20/80OS 20/80


WBC: 19.8WBC: 19.8

RBC: 1.13RBC: 1.13

HGB: 4.4HGB: 4.4

HCT: 12.8HCT: 12.8

PLT: 14.0PLT: 14.0

BLASTS: 80BLASTS: 80

LEUKEMIALEUKEMIA

Group of blood disorders with abnormal, Group of blood disorders with abnormal, unregulated proliferation of WBC.unregulated proliferation of WBC.

Acute (80% children) or chronicAcute (80% children) or chronic

Lymphoid: B-cell and T-cellLymphoid: B-cell and T-cell

MyeloidMyeloid

Accounts for 3.7% of cancer deaths Accounts for 3.7% of cancer deaths

LEUKEMIALEUKEMIA

OCULAR MANIFESTATIONSOCULAR MANIFESTATIONS::

50-80% ocular involvement50-80% ocular involvement

Leukemic infiltratesLeukemic infiltrates

Secondary complications related to: Secondary complications related to:

-anemia-anemia

-thrombocytopenia-thrombocytopenia

-hyperviscosity-hyperviscosity

Opportunistic infectionsOpportunistic infections

RETINOPATHY AS AN INITIAL SIGN OF SYSTEMIC DISEASE


WALDENSTROM’S MACROGLOBULINEMIAWALDENSTROM’S MACROGLOBULINEMIA

LEUKEMIALEUKEMIA


60 yo WF60 yo WF

Loss of vision ODLoss of vision OD

Eyeball achinessEyeball achiness

Red and puffy ODRed and puffy OD

PMH: Hysterectomy, hernia, hypertension, PMH: Hysterectomy, hernia, hypertension, skin Ca skin Ca

PATIENT HISTORY PATIENT HISTORY contcont..

EXAMINATIONEXAMINATION

OD: 20/60, OS: 20/20OD: 20/60, OS: 20/20

Massive sclerochoroidal swelling with Massive sclerochoroidal swelling with localized localized orbital pseudotumor OD.orbital pseudotumor OD.

Proptosis OD.Proptosis OD.

Prominent, elevated Prominent, elevated mass at the mass at the sclerochoroidal levelsclerochoroidal levelAcoustically solid Acoustically solid Shallow retrobulbar Shallow retrobulbar echolucent spaceecholucent space

A-scan: high internal A-scan: high internal reflectivityreflectivity

Pathology ReportPathology Report

Scleral tissue: mild to Scleral tissue: mild to moderately infiltrated moderately infiltrated with chronic with chronic inflammatory cells.inflammatory cells.

Evidence of scleral Evidence of scleral necrosis.necrosis.

No evidence of No evidence of tumor.tumor.

5 years later5 years later

GIANT NODULAR POSTERIOR GIANT NODULAR POSTERIOR

SCLERITIS SIMULATING SCLERITIS SIMULATING

CHOROIDAL MELANOMACHOROIDAL MELANOMA

Review of 400 patients with lesions Review of 400 patients with lesions clinically simulating choroidal clinically simulating choroidal

melanomamelanoma

Suspicious choroidal nevus 27%Suspicious choroidal nevus 27%Age-related macular degeneration 13%Age-related macular degeneration 13%Age-related extramacular degen. 11%Age-related extramacular degen. 11%Congenital hypertrophy of RPE 10%Congenital hypertrophy of RPE 10%Choroidal hemangioma 8%Choroidal hemangioma 8%Nodular scleritisNodular scleritis 1.5%1.5%

Shields JA, Augsburger JJ, Brown GC, Shields JA, Augsburger JJ, Brown GC, Stephens RF: The differential diagnosis of Stephens RF: The differential diagnosis of posterior uveal malanoma. Ophthalmology, posterior uveal malanoma. Ophthalmology, 1980; 87: 518-5221980; 87: 518-522

NODULAR POSTERIOR SCLERITISNODULAR POSTERIOR SCLERITIS

Inflammatory sclerochoroidal massInflammatory sclerochoroidal mass

Systemic disease in 10% of patientsSystemic disease in 10% of patients

UnilateralUnilateral

AdultsAdults

Blurred vision with pain and red eyeBlurred vision with pain and red eye

Exudative retinal detachmentExudative retinal detachment

A/B scan, CT, MRI helpfulA/B scan, CT, MRI helpful

Systemic corticosteroid therapySystemic corticosteroid therapy


27 yo, HEALTHY WM27 yo, HEALTHY WM

CC: BLURRED VA OD X6 WEEKSCC: BLURRED VA OD X6 WEEKS

PMH: BELL’S PALSYPMH: BELL’S PALSY

VA: OD 20/80, OS 20/40. VA: OD 20/80, OS 20/40.


CBC: NLCBC: NLESR: 2ESR: 2ACE: NLACE: NLLYSOZYME: NLLYSOZYME: NLLYME TITER: NLLYME TITER: NL

ANA: SL. POSITIVE ANA: SL. POSITIVE (1:80)(1:80)HEPATITIS A,B,C: NEGHEPATITIS A,B,C: NEGANTICARDIOLIPIN: ANTICARDIOLIPIN: NEGNEGC-ANCA, P-ANCA: NEGC-ANCA, P-ANCA: NEGSEROLOGY: NEGSEROLOGY: NEG

FOLLOW-UP (6 MONTHS)FOLLOW-UP (6 MONTHS)

CC: PROGRESSIVE LOSS OF VISIONCC: PROGRESSIVE LOSS OF VISION

VA: OD 20/400, OS 20/80VA: OD 20/400, OS 20/80

FUNDUS: SEVERE ONH EDEMAFUNDUS: SEVERE ONH EDEMA

PROGRESSIVE EXUDATIONPROGRESSIVE EXUDATION

DX: R/O OPTIC NEURITIS, MENINGIOMADX: R/O OPTIC NEURITIS, MENINGIOMA

RX: SYSTEMIC STEROIDSRX: SYSTEMIC STEROIDS

FOLLOW-UP (1 YEAR)FOLLOW-UP (1 YEAR)

VA: OD NLP, OS 20/40VA: OD NLP, OS 20/40

SLE: SEVERE RUBEOSIS IRIDIS ODSLE: SEVERE RUBEOSIS IRIDIS OD

FUNDUS: ONH EDEMA, EXUDATIONFUNDUS: ONH EDEMA, EXUDATION

RX: LASER PHOTOCOAGULATIONRX: LASER PHOTOCOAGULATION

NEURORADIOGRAPHIC FINDINGSNEURORADIOGRAPHIC FINDINGS

CHEST X-RAY: CHEST X-RAY: NEGNEG

MRI: ENLARGED MRI: ENLARGED RIGHT OPTIC RIGHT OPTIC NERVENERVE

May 2001 May 2001 August 2002August 2002

OPTIC NERVE BIOPSYOPTIC NERVE BIOPSY

Dense collagenous stroma with inflammatory infiltrates of Dense collagenous stroma with inflammatory infiltrates of plasma cells, lymphocytes, histiocytes and neutrophilsplasma cells, lymphocytes, histiocytes and neutrophils

IDIOPATHIC SCLEROSING IDIOPATHIC SCLEROSING INFLAMMATION OF THE ORBITINFLAMMATION OF THE ORBIT

Autoimmune diseaseAutoimmune disease

Progressive infiltrative fibrosisProgressive infiltrative fibrosis

Chronic courseChronic course

Visually disableVisually disable

Treatment unsatisfactoryTreatment unsatisfactory


50 y/o healthy, W/F50 y/o healthy, W/F

C/O: blurred and distorted VA OD x 2-3 yrs.C/O: blurred and distorted VA OD x 2-3 yrs.

VA :VA :

OD: 20/80OD: 20/80

OS: 20/20 OS: 20/20

CHOROIDAL OSTEOMACHOROIDAL OSTEOMA

Mostly womenMostly women

Mature boneMature bone

Well defined round or ovalWell defined round or oval

Orange, white or white-yellowOrange, white or white-yellow

Juxtapapillary and macular areaJuxtapapillary and macular area

Bilateral 20%, most often young womenBilateral 20%, most often young women

Ultrasonography: calcificationUltrasonography: calcification

Patient HistoryPatient History

14 y/o w/f, mother noticed that pupil was 14 y/o w/f, mother noticed that pupil was turning white over the past few months.turning white over the past few months.

PMH : unremarkablePMH : unremarkableVA : OD CF VA : OD CF

OS 20/20OS 20/20

COATS’ DISEASECOATS’ DISEASE

Retinal telangiectasis with exudative RDRetinal telangiectasis with exudative RDUnilateral, male to female 3 to 1Unilateral, male to female 3 to 1Young children under age 16Young children under age 16Poor vision, strabismus or leukocoriaPoor vision, strabismus or leukocoriaSubretinal yellowish to greenish exudationSubretinal yellowish to greenish exudationRetinal telangiectasisRetinal telangiectasisManagement: photocoagulation, Management: photocoagulation, cryotherapy, vitrectomycryotherapy, vitrectomy


PH: 19 WM college student who reports decreased PH: 19 WM college student who reports decreased vision OU x 3 wks. Recent cold/flu-like vision OU x 3 wks. Recent cold/flu-like symptoms.symptoms.

PMH: UnremarkablePMH: Unremarkable

Exam:Exam: ODOD 20/200 phni20/200 phni IOPIOP 1313OSOS 20/200 phni20/200 phni 1313

BPBP 132/78132/78

2 Week F/U at Univ. of Kentucky 2 Week F/U at Univ. of Kentucky Medical CenterMedical Center

Complains of headachesComplains of headaches

Blood pressure 240/150 on multiple Blood pressure 240/150 on multiple checkschecks

Positive ANAPositive ANA

SED rate 55SED rate 55

MRI (head and orbits) NormalMRI (head and orbits) Normal

Hypertensive RetinopathyHypertensive Retinopathy

ESSENTIAL HYPERTENSIONESSENTIAL HYPERTENSION

(no known cause)(no known cause)

SECONDARY HYPERTENSIONSECONDARY HYPERTENSION

Preeclampsia/eclampsiaPreeclampsia/eclampsia

kidney diseasekidney disease

adrenal diseaseadrenal disease

coarctation of the aortacoarctation of the aorta


PH: 12 yr. WM c/o decreased vision OD x 5 PH: 12 yr. WM c/o decreased vision OD x 5 days. Flu-like symptoms 1 week prior.days. Flu-like symptoms 1 week prior.

PMH: HealthyPMH: Healthy

EXAM:EXAM: ODOD CF @ 4 ft. CF @ 4 ft. IOPIOP 1212

OSOS 20/2020/20 1212

Serologic Work UpSerologic Work Up

HLA B27HLA B27 NEGATIVENEGATIVEFTA-ABSFTA-ABS NON-REACTIVENON-REACTIVEANAANA NEGATIVENEGATIVERA quant.RA quant. NORMALNORMALRPRRPR NON-REACTIVENON-REACTIVEHIVHIV NEGATIVENEGATIVEACEACE NORMALNORMALCAT SCRATCH AB-RCAT SCRATCH AB-R POSITIVEPOSITIVESED RATESED RATE 6161CXRCXR NORMALNORMAL

Acute Neuroretinitis Secondary to Acute Neuroretinitis Secondary to Cat Scratch DiseaseCat Scratch Disease

Bartonella henselaeBartonella henselae is the causative is the causative organismorganismVA loss may be mild or severeVA loss may be mild or severe33% of cases may be bilateral33% of cases may be bilateral> 90% improve to 20/40 within 8 weeks > 90% improve to 20/40 within 8 weeks and 20/20 within 6 monthsand 20/20 within 6 monthsSmall subgroup left with severe visual loss Small subgroup left with severe visual loss and associated optic atrophyand associated optic atrophy

TreatmentTreatment

No proven treatmentNo proven treatment

Periocular and systemic corticosteriodsPeriocular and systemic corticosteriods

Antibiotic therapy Antibiotic therapy

No difference in treated vs. untreated No difference in treated vs. untreated patientspatients


PH: 50yr. WF who reports distortion and PH: 50yr. WF who reports distortion and occasional blurred vision OU x 6 yrs.occasional blurred vision OU x 6 yrs.

PMH: Breast lumpectomy (benign), trauma PMH: Breast lumpectomy (benign), trauma (auto accident) and Bell’s palsy.(auto accident) and Bell’s palsy.

POH: Glaucoma OU.POH: Glaucoma OU.

EXAM:EXAM: 20/40 phni20/40 phni IOPIOP 1717

20/60 phni20/60 phni 1717

BPBP 140/78140/78

Geographic Helicoid Peripapillary Geographic Helicoid Peripapillary Choroiditis Choroiditis

(Serpiginous choroiditis)(Serpiginous choroiditis)

• CHRONIC RECURRING CHOROIDITISCHRONIC RECURRING CHOROIDITIS• MULTIFOCALMULTIFOCAL• INNER CHOROID & RPEINNER CHOROID & RPE• INFLAMMATION vs. SRNVINFLAMMATION vs. SRNV

TreatmentTreatment

Steroids (oral or periocular injection)Steroids (oral or periocular injection)

Photocoagulation for SRNVMPhotocoagulation for SRNVM

Anti - VEGFAnti - VEGF


25 y/o , w/f was seen for the 125 y/o , w/f was seen for the 1stst time on Feb. time on Feb. 1616thth 2010 2010

c/o intermittent blurring of central vision c/o intermittent blurring of central vision which started 2 mo ago and last about 4-5 which started 2 mo ago and last about 4-5 hours. hours.

Her visual symptoms increased recently Her visual symptoms increased recently and last longer.and last longer.

PMH: unremarkable.PMH: unremarkable.

Case 4

ExaminationExamination

Visual acuityVisual acuity– OD 20/60OD 20/60 OD 16 mm HgOD 16 mm Hg– OS 20/40OS 20/40 OS 14 mm HgOS 14 mm Hg

SLE: SLE: a few vitreous cells.a few vitreous cells.Fundus:Fundus:

Hyperemic optic nerves, OUHyperemic optic nerves, OUCystoid macular edema, OUCystoid macular edema, OU

FANG: FANG: CME with ON leakage, OUCME with ON leakage, OUOCT: Thickened neuroepithelium with large OCT: Thickened neuroepithelium with large

cystic cystic changes, OU changes, OU

Feb. 16Feb. 16thth 2010 2010

Feb. 16Feb. 16thth 2010 2010

OD

OS

Laboratory Work-upLaboratory Work-up

CBCCBC NormalNormal

ESRESR NormalNormal

CRPCRP NormalNormal

RFRF NormalNormal

ANAANA NormalNormal

ACEACE NormalNormal

RPRRPR Non-reactiveNon-reactive

FTA-AbsFTA-Abs Non-reactiveNon-reactive

CXRCXR NormalNormal

MRIMRI NormalNormal

Feb 23Feb 23rdrd 2010 2010

No visual complaintsNo visual complaints

VAVA– ODOD 20/2020/20– OSOS 20/2020/20

Fundus:Fundus:– Macula and optic nerve flat OUMacula and optic nerve flat OU

OCT: OCT: NormalNormal

Feb. 23Feb. 23rdrd 2010 2010

OD

OS

March 16March 16thth 2010 2010

C/O blurred vision since March 3C/O blurred vision since March 3rdrd OU OU

On further questioning, she reported that all On further questioning, she reported that all episodes of blurred vision would start with each episodes of blurred vision would start with each menstrual period (21 days), last the first half of menstrual period (21 days), last the first half of each cycle, and resolve at the end of each cycle, and resolve at the end of menstruation. No oral contraceptionmenstruation. No oral contraception

VA: 20/80 OUVA: 20/80 OUFundus: CME with congested ON, OU.Fundus: CME with congested ON, OU.OCT: CMEOCT: CME

BibliographyBibliography

Cyclic Presentation of CME: A. Assi, J. Hickman Casey, Cyclic Presentation of CME: A. Assi, J. Hickman Casey, et al.: Acta Ophthalmol. Scand. 1998: 76: 245-246et al.: Acta Ophthalmol. Scand. 1998: 76: 245-246

– Presented the case of a 28 y/o lady with unilateral pars planitis Presented the case of a 28 y/o lady with unilateral pars planitis and associated CME in whom visual symptoms fluctuated and associated CME in whom visual symptoms fluctuated regularly during menstrual cycles.regularly during menstrual cycles.

Cyclical central serous chorloretinopathy associated Cyclical central serous chorloretinopathy associated with cystoid macular oedema. with cystoid macular oedema. Birchall W, Charles SJ, Birchall W, Charles SJ, Buckler HM. BJO 2001 Jun;85(6):756-8.Buckler HM. BJO 2001 Jun;85(6):756-8.

– CME resolved on oral contraceptives.CME resolved on oral contraceptives.

Consultations and Work-upConsultations and Work-up

GynecologicalGynecological NormalNormal

EndocrineEndocrine NormalNormal

ImmunologicalImmunological NormalNormal

Clotting Clotting APC, R 0.6APC, R 0.6

TreatmentTreatment

August 20August 20thth, 2010., 2010.– Oral contraceptive pill Yasminelle.Oral contraceptive pill Yasminelle.– Her cycle from 21 days changed to 28 days Her cycle from 21 days changed to 28 days

with initial improvement of her visual with initial improvement of her visual symptoms for 2-3 months.symptoms for 2-3 months.

November 11November 11thth, 2010, 2010– Started on stronger contraceptive pill, Yasmin, Started on stronger contraceptive pill, Yasmin,

with subjective visual improvement. with subjective visual improvement.

Dec 20Dec 20thth 2010 2010

Reports visual improvementReports visual improvement

On oral contraceptives for 4 monthsOn oral contraceptives for 4 months

VA VA – OD 20/60OD 20/60– OS 20/40OS 20/40

Dec 20Dec 20thth 2010 2010

OD

OS

Beginning of Jan. 2011 developed progressive Beginning of Jan. 2011 developed progressive painful ophthalmoplegia OD which was attributed to painful ophthalmoplegia OD which was attributed to a large brain mass. It was not present at her initial a large brain mass. It was not present at her initial

evaluation by MRI.evaluation by MRI.

Biopsy revealed inflammatory compounds.Biopsy revealed inflammatory compounds.

Was treated with IV antibiotics with complete Was treated with IV antibiotics with complete

regression of her ophthalmoplegiaregression of her ophthalmoplegia..

10/02/201127/05/2013

26/04/2011

Happy EndingHappy Ending

Patient got married and is expecting Patient got married and is expecting

a baby soon.a baby soon.

She is on no medications.She is on no medications.

No visual complaints.No visual complaints.

VA: 20/20 OU.VA: 20/20 OU.

QuestionsQuestions

Etiology of Cyclic Presentation of CME.Etiology of Cyclic Presentation of CME.

Treatment?Treatment?

If anyone in the audience has come If anyone in the audience has come across with a similar case, please shareacross with a similar case, please share..

THANK YOUTHANK YOU

Health & Medicine

Kranias diagnostic challenges in retinal diseases 06 20 14