The purpose of this review is to provide an overview of visual snow (VS) and provide information regarding current treatment options for VS. Visual snow (VS) is a rare disorder manifesting with a persistent visual phenomenon of seeing numerous tiny snow-like dots throughout the visual field, and it can cause debilitating visual and psychological consequences. It is emerging as a disorder separate from, but associated with, migraine visual aura, and neuronal cortical hyperexcitability is being considered as a theoretical mechanism for the persistent-positive visual symptoms. There are few studies that have investigated the treatment of VS, but as our understanding of this entity begins to change, we expect that new treatment approaches and treatment trials will emerge in the next decade. Currently, our approach is to consider pharmacologic treatment for all patients with VS who report decreased quality of life as a result of VS. Resolution of the disorder is difficult to accomplish with treatment, but in our experience, even when symptom intensity is simply reduced, many patients find that there is an improvement in their quality of life that is beneficial. Our preferred treatment options include: (1) oral lamotrigine with a slow increase from 25 mg daily to a maintenance dose of 200-300 mg daily in divided doses as tolerated, and this is typically achieved by advancing the dose in increments of 25-50 mg weekly following the first 2 weeks of therapy; (2) oral acetazolamide with an initial dose of 250 mg daily followed by a slow increase over 1-2 weeks to a total of 1000 mg daily in divided doses, and higher doses can be tolerated by some without increasing the risk-benefit ratio; or (3) oral verapamil long-acting at 120-240 mg daily, and if side effects limit the dose the can be initiated, then lower doses with short-acting verapamil two or three times daily can be substituted until higher doses with the long-acting formula can be tolerated. By initiating drug treatments with low doses and slowly increasing over 1 to 4 weeks, tolerability and compliance improves and allows patients to realize the full benefits of treatment. The proposed mechanisms of microstructural cortical abnormalities and hyperexcitability as a cause of VS may lead to new treatment approaches in the future. Until such a time, medications reported to relieve persistent visual phenomena of migraine and visual aura of migraine are treatment options worth considering and these are reviewed for that purpose. Although clinical trials for the treatment of visual snow are lacking due to the rarity of the disorder, medications reviewed here should be considered for use in patients with VS who experience an impact on their quality of life. Theoretical mechanisms that lead to cortical hyperexcitability are being investigated and could lead to new treatment options. In the meantime, medications may provide benefits in this disabling condition.

IMPORTANCEA review of the injury patterns, treatment strategies, and responding physicians' experience during the Port of Beirut blast may help guide future ophthalmic disaster response plans.OBJECTIVE To present the ophthalmic injuries and difficulties encountered as a result of the Port of Beirut blast on August 4, 2020. DESIGN, SETTING, AND PARTICIPANTSA retrospective medical record review of all patients who presented to the emergency department and 13 ophthalmology outpatient clinics at the American University of Beirut Medical Center for treatment of ophthalmic injuries sustained from the explosion in Port of Beirut, Beirut, Lebanon, from August 4 to the end of November 2020. Patients were identified from emergency records, outpatient records, and operative reports.MAIN OUTCOMES AND MEASURES Types of ocular injuries, final best-corrected visual acuity, and need for surgical intervention were evaluated. Visual acuity was measured with correction based on noncycloplegic refraction using the Snellen medical record. EXPOSURES Ocular or ocular adnexal injuries sustained from the Port of Beirut explosion.RESULTS A total of 39 blast survivors with ocular injuries were included in this study. Twenty-two patients presented with ocular injuries on the day of the blast, and 17 patients presented within the following 3 months to the ophthalmology clinics for a total of 48 eyes of 39 patients were treated secondary to the blast. Thirty-five patients (89.6%) were adults, and 24 (61.5%) were female. A total of 21 patients (53.8%) required surgical intervention, more than half of which were urgently requested on the same day of presentation (14 [35.9%]). Most eye injuries were caused by debris and shrapnel from shattered glass leading to surface injury (26 [54.2%]), eyelid lacerations (20 [41.6%]), orbital fractures (14 [29.2%]), brow lacerations (10 [20.8%]), hyphema (9 [18.8%]), open globe injuries (10 [20.8%]), and other global injuries. Only 7 injured eyes (14.5%) had a final best-corrected visual acuity of less than 20/200, including all 4 open globe injuries with primary no light perception (8.3%) requiring enucleation or evisceration. CONCLUSIONS AND RELEVANCEIn the aftermath of the Port of Beirut explosion, a review of the ophthalmic injuries showed a predominance of shrapnel-based injuries, many of which had a delayed presentation owing to the strain placed on health care services. Reverting to basic approaches was necessary in the context of a malfunctioning electronic medical record system.

Although the cause of delayed onset diplopia after successful treatment is still unknown, theories include late compression of cranial nerves within the cavernous sinus due to coil mass that can cause chronic ischemia, delayed inflammation due to a thrombophilic nidus created by the coil mass, or injury to the cranial nerves that manifests later due to decompensated strabismus.

PurposeTo assess the evolution of retinal findings in patients with membranoproliferative glomerulonephritis (MPGN) by funduscopy, intravenous fluorescein angiography and optical coherence tomography.ObservationsThree women and one man were followed for a period of 1.5–37 years. Four patients (8 eyes) had drusen detected at first fundus exam at age 24, 29, 50 and 55. Three patients (6 eyes) had diffuse thickening of Bruch's membrane, and two patients (3 eyes) had detachment of the retinal pigment epithelium with serous retinal detachment. Drusen tended to widen over a period of 10-year follow-up in one case.Conclusions and importanceDrusen remain the ocular stigmata for MPGN occuring at an early age. The retinal disease is progressive with gradual thickening of Bruch's membrane and occurrence of retinal pigment epithelium detachment.

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