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Kanwaljeet Harjot Madan
This 32YO diabetic male presented with profound vision loss following rhino-orbital-cerebral mucormycosis, for which he had undergone orbital exenteration 8 months earlier. Vision was no light perception with a fixed and mid-dilated pupil.
Color photography shows a pale nerve with blood on and surrounding the disc, with a striking narrow white vascular tree. OCT angiography shows virtually no flow signals in the thinned, atrophic, hyperreflective inner and mid-retinal layers.
Learning Points:
Mucormycosis is an angioinvasive fungal infection, most often affecting patients with poorly controlled diabetes (especially ketoacidosis), immunosuppression, or iron overload (Kontoyiannis et al, NEJM 2026;394:684-698). Its hallmark is hyphal invasion of vessel walls, producing thrombosis and ischemic necrosis. In the rhino-orbital-cerebral form, the fungus seeds the sinuses and spreads to the orbit, ophthalmic artery, and optic nerve, with intracranial extension via the cavernous sinus.
Direct fungal infiltration of the central retinal artery can result in devastating retinal ischemia, and combined retinal and optic nerve infarction may cause irreversible vision loss. CRAO may also herald further life-threatening vascular complications, including stroke, arising from hyphal luminal growth, endothelial injury, and vasculitis (Kamath et al, Indian J Ophthalmol 2023;71:2904-2906). These events often occur despite anticoagulation and carry high mortality, underscoring the need for urgent liposomal amphotericin B and surgical debridement.
Graefes Arch Clin Exp Ophthalmol. 2026 Sep;264(9):2783-2793. doi: 10.1007/s00417-026-07241-0.
Charles Bonnet syndrome present in 5% of patients referred for cataract surgery, most without retinal pathology and associated with lower VA in the better-seeing eye — Prospective, 391 patients
Purpose: To investigate the prevalence and clinical characteristics of Charles Bonnet Syndrome (CBS) in patients referred for bilateral cataract surgery.
Methods: This prospective, cross-sectional clinical trial included 391 patients attending cataract assessment at a single-center tertiary cataract clinic. After clinical examination, participants were screened for presence of visual hallucinations (VHs). Participants experiencing complex VHs were further questioned regarding characteristics of their hallucinatory experiences to properly determine if they were attributable to CBS. CBS was defined as complex visual hallucinations with retained insight, no medical history or medication known to cause hallucinations and not limited to hypnagogic or hypnopompic states (hallucinations happening shortly before falling asleep and/or shortly after waking up).
Results: Nineteen (4.9%) patients experienced complex VHs. Of these, 11 (2.8%) were diagnosed with CBS while 8 (2.1%) had complex hypnagogic and/or hypnopompic VHs. Multivariable logistic regression analysis identified lower best-corrected visual acuity (BCVA) in the better seeing eye as a significant predictor of CBS. When excluding participants with a BCVA>0.3, prevalence of complex VHs rose to 10.0%. Three of the patients with CBS (27.3%) had ocular comorbidities: two had exudative age-related macular degeneration (AMD), and one had drusenoid AMD. In the overall cohort, twenty-four patients (6.1%) reported prior knowledge of CBS. CONCLUSION: CBS was observed in a clinically relevant minority of cataract patients requiring bilateral surgical intervention. Given the high prevalence of cataract among the elderly, this study highlights the importance of healthcare personnel being aware of CBS and other complex VHs and their potential consequences for cataract patients.
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