Bilateral Episcleral Corkscrew Vessels: Expedition into the Unknown – Case Report

We aim to report a case of a middle-aged woman with bilateral idiopathic elevated episcleral venous pressure (IEEVP) and its difficulties in the diagnostic approach. Particularly in this case, the atypical feature of ocular hypertension without glaucomatous optic nerve damage may be misleading. We present a 66-year-old woman with longstanding bilateral “red eyes.” Clinical findings included bilateral episcleral vessel engorgement and tortuosity and raised intraocular pressure with open iridocorneal angles. Despite ocular hypertension, glaucomatous neuropathy was absent and confirmed by normal structural (optical coherence tomography) and functional (standard automated perimetry) tests. The systemic workup was unremarkable. Magnetic resonance angiography showed bilateral dilated superior ophthalmic veins. Cerebral digital subtraction angiography was requested, and no carotid-cavernous fistula (or other significant vascular findings) was identified. The diagnosis of IEEVP was assumed. In conclusion, our case highlights the systematic investigation necessary in cases of bilateral episcleral vessel engorgement and tortuosity and the possible differential diagnosis to be considered to rule out life-threatening causes of elevated episcleral venous pressure. It is important for clinicians to be aware of IEEVP even in patients with atypical features that despite significative ocular hypertension had no glaucomatous damage.

Effect of Prior Phacoemulsification Surgery in Trabeculectomy Surgery Outcomes

Purpose

Methods

Results

Conclusion

Covid-19 Impact on Macular Neovascularization and Retinal Vein Occlusion Treatment: Single-Center Experience

Purpose

The aim of this study was to evaluate whether the coronavirus disease 19 (COVID-19) pandemic resulted in undertreatment and subsequent loss of visual acuity (VA) in patients with macular neovascularization (MNV) or retinal vein occlusion (RVO) regularly treated with intravitreal antivascular endothelial growth factor injections.

Methods

Single-center, retrospective study of patients scheduled for treatment between March 19 and June 1, 2020, the national mandatory quarantine period. Patients' demographics, VA, and scheduled treatment during this period were reviewed via medical records. All patients were analyzed regarding treatment attendance rates. The visual impact of COVID-19 was assessed in patients who had been treated and presented a stable VA for >6 months before the beginning of the quarantine.

Results

This study included 927 eyes from 769 patients. The attendance rate increased throughout the study timeframe (p < 0.001) and correlated negatively with higher patient's age (r = -0.142; p = 0.005). Patients with age-related macular degeneration (67.6%) had lower attendance rates (p = 0.007) and were older (p < 0.001). The visual impact analysis included 400 eyes from 325 patients. The average VA variation throughout this period was -1.7 ± 8.4 ETDRS letters and was similar in different retinal pathologies (p = 0.334). VA variation did not correlate with the number of missed treatments per patient (r = 0.100; p = 0.150). The prevalence of subretinal fluid and intraretinal fluid, as well as central retinal thickness decreased significantly throughout the study period (p values of <0.001, <0.001, and 0.032, respectively).

Conclusion

The COVID-19 pandemic had a significant impact on the attendance rate of patients with MNV or RVO to their scheduled treatments, which was higher in the first week of mandatory quarantine. Nevertheless, VA did not decrease significantly during this period, with a limited VA variation regardless of primary retinal disorder and morphological parameters even improved in the eyes included in the visual impact analysis.

Longitudinal multimodal functional macular analysis after half-dose photodynamic therapy for central serous chorioretinopathy

BACKGROUND

Half-dose photodynamic therapy (HD-PDT) has been widely used for central serous chorioretinopathy (CSC) with good anatomical results. However, long-term functional outcomes after this treatment remain uncertain. This study aimed a longitudinal multimodal macular assessment, correlating functional and anatomical outcomes.

METHODS

This is a retrospective study performed in a tertiary referral center including 111 eyes from 95 CSC patients. Data on best corrected visual acuity (BCVA), central macular thickness (CMT), central retinal sensitivity (CRS) using microperimetry (MP) and multifocal electroretinography (mfERG) at baseline and 3, 6, 12, 18, 24, 36, 48 and 60 months after treatment were registered. A correlation analysis was performed.

RESULTS

Mean follow-up was 34.5 ± 26.3 months. A significant improvement in BCVA and CMT was registered in all the visits. CRS significantly improved until 24 months (p<0.001 at 12 months, p<0.05 at 24 months), worsening afterwards. The mfERG amplitude of N1 and P1 waves significantly improved in the first 12 months, aggravating afterwards. The implicit time improved until 24 months, deteriorating after 48 months. This long-term decline was also described in some inactive untreated fellow eyes CONCLUSIONS: : A multimodal longitudinal analysis of CSC patients after HD-PDT shows that, after the first 12 to 24 months, the significant sustained improvement in BCVA and CMT is not paired by a sustained improvement in macular sensitivity or electrical response. This long-term functional deterioration might result from the disease itself and not directly from the treatment.

A painful red eye in an intravenous drug abuser: When not everything is what it seems

INTRODUCTION

Endogenous endophthalmitis is a rare but devastating ocular infection, resulting from microbial seeding of the eye during bacteremia or fungemia. Among other sources of septicemia, intravenous drug abuse is a significant risk factor, and endogenous endophthalmitis should always be thought of in any patient with a history of injectable drug use, presenting with a painful vision loss and a red inflamed eye.

CASE DESCRIPTION

We report the case of a 47-year-old male, with a history of injectable drug consumption, who presented to our emergency department complaining of a painful red eye and recent deterioration of visual acuity. After the first clinical hypothesis of endogenous endophthalmitis being considered, the final diagnosis of Human Leukocyte Antigen (HLA) B27-associated acute anterior uveitis was established.

CONCLUSION

Ocular inflammation is one of the most challenging fields in all ophthalmology. Several inflammatory disorders, ranging from a wide variety of infectious and non-infectious conditions, can present themselves with the same clinical signs and symptoms, making their diagnosis extremely defiant.

Two Novel Disease-Causing Variants in the PDE6C Gene Underlying Achromatopsia

We report the clinical phenotype and genetic findings of two variants in PDE6C underlying achromatopsia (ACHM). Four patients with the variant c.1670G>A in exon 13 of the PDE6C gene were identified. Additionally, one had compound heterozygous genotype, with two variants in the PDE6C gene, a variant of c.2192G>A in exon 18 and c.1670G>A in exon 13. All patients presented the symptomatic triad of decreased visual acuity, severe photophobia, and colour vision disturbances. SD-OCT showed an absence of the ellipsoid zone, creating an optically empty cavity at the fovea in three patients. The patient with the compound heterozygous genotype presented a more severe subfoveal outer retina atrophy. ERG recordings showed extinguished responses under photopic and 30-Hz flicker stimulation, with a normal rod response. We identified two new variants in the PDE6C gene that leads to ACHM.

Increased Choroidal Thickness in Morquio Syndrome

The purpose of this clinical case report is to describe a case of mucopolysaccharidosis type IVA (MPS IVA), or Morquio syndrome, with increased choroidal thickness in enhanced-depth imaging optical coherence tomography (EDI-OCT) which can represent choroidal deposition of glycosaminoglycans (GAGs). A 21-year-old male with genetically confirmed diagnosis of MPS IVA was examined at our Pediatric Ophthalmology clinic as part of our follow-up protocol for MPS patients. His best-corrected visual acuity was 4/10 in his right eye (OD) and 6/10 in the left eye (OS). Mild diffuse corneal opacification was evident. Intraocular pressure was within normal range. Fundus examination and color fundus photography revealed no abnormalities. EDI-OCT revealed significantly increased choroidal thickness in his right eye and in his left eye, suggesting the presence of choroidal deposition of GAGs, despite absence of retinal or optic disc GAG deposition or other chorioretinal involvement. To our knowledge, this is the first case of MPS IVA described in the literature with suspected choroidal deposition of GAGs. With improved control of systemic features of MPS IVA, life expectancy of these patients has increased, allowing for more ocular manifestations to develop. The parallel development of technology in ophthalmology, such as the EDI-OCT, further contributes to the detection of these unprecedented ocular features in MPSs.

Quantitative Optical Coherence Tomography Angiography Biomarkers for Alport Syndrome

PURPOSE

The aim of this study was to evaluate microvascular abnormalities of patients with Alport syndrome (AS) using optical coherence tomography angiography (OCT-A) quantitative biomarkers.

METHODS

This was cross sectional, prospective evaluation of consecutive patients with AS and healthy subjects. AS diagnosis was performed by the genetic test. All participants underwent a retinal vasculature evaluation by spectral-domain optical coherence tomography (SD-OCT) and OCT-A of the macula. Quantitative analysis included whole vascular density, foveal avascular zone area, fractal dimension (FD), and lacunarity (LAC).

RESULTS

Ninety-four eyes were included in this study, 45 eyes from patients with AS and 49 eyes from healthy subjects. The pathogenic mutation in the COL4A5 gene on the chromosome X was found in 14 patients; the pathogenic autosomal recessive mutations in the COL4A3 gene were found in 9 patients. Quantitative evaluation demonstrated a significant difference between AS and healthy subjects on LAC of the superficial capillary plexus and deep capillary plexus (DCP) (p < 0.001 and p < 0.001, respectively) and on FD in the DCP (p < 0.001).

CONCLUSION

The DCP Alport patients have a higher vessel nonuniformity than DCP of healthy subjects. We hypothesize that endothelial cell lesion in the setting of low resistance at the DCP circuit could lead to long-term structural disorganization.

Traumatic Cyclodialysis Cleft Treatment Combined with Cataract Surgery: An Original Triple Procedure

Introduction

To describe a “triple” surgical procedure, which combined traumatic cataract extraction by phacoemulsification with gas endotamponade and cyclocryotherapy in the successful treatment of a traumatic cyclodialysis cleft.

Methods

A 44-year-old man who suffered severe left eye blunt trauma with an elastic band developed a 4-hour extent cyclodialysis cleft with consequent hypotony. After 7 weeks of persistent hypotonic maculopathy unresponsive to medical treatment, and with an evolving traumatic cataract, the patient underwent cataract surgery combined with intravitreal gas endotamponade (20% SF6) and cyclocryotherapy.

Results

Two weeks after the procedure the intraocular pressure increased to 12 mmHg and remained steady during the next 14 months of follow-up. Hypotonic maculopathy resolved and successful closure of the cyclodialysis cleft was confirmed by gonioscopy and ultrasound biomicroscopy.

Conclusion

Gas endotamponade and cyclocryotherapy constitute a promising option in the treatment of cyclodialysis clefts unresponsive to medical therapy. In our case, this minimally invasive technique was innovatively combined with cataract surgery. Despite early postoperative intraocular inflammation, a successful outcome was achieved.

Long-term progression of geographic atrophy in age-related macular degeneration does the phakic status matter?

PURPOSE

To assess the long-term risk of geographic atrophy (GA) progression after cataract surgery.

METHODS

Subjects with GA secondary to AMD followed for at least 1 year with fundus autofluorescence imaging and with at least two visits at our centre were included. Patients with wet AMD, disciform scar, past history of intravitreal injections or laser treatment, other maculopathies and with poor quality images were excluded. GA area at baseline and at follow-up visit was measured. Three study groups were defined according to their phakic status: (A) pseudophakia, (B) phakic and (C) phacoemulsification surgery performed during the study. Differences of GA area progression were compared between these study groups. In addition, comparison between GA progression rate in group (C) before and after the surgery was performed. The enlargement rate (ER) was calculated for lesion size after transforming the measurements to the square-root scale.

RESULTS

A total of 92 eyes of 92 patients were enrolled. Median follow-up time was 4 [1-10] years. Regarding the eye's phakic status, 29 (31.5%) were pseudophakic and 63 (68.5%) were phakic; of these, 22 underwent phacoemulsification during the study. Overall, the median baseline and follow-up area of GA were 1.42 [0.04-32.10] mm² and 6.48 [0.25-47.40] mm², respectively. The ER was similar between phakic and pseudophakic eyes (0.18 [0.01-1.03] vs 0.15 [0.01-0.65] mm/year, p = 0.62). In patients that underwent cataract surgery during the study, the GA ER remained stable (0.13 [0.01-0.92] vs 0.14 [0.01-0.63] mm/year, p = 0.43).

CONCLUSION

These results suggest that cataract surgery does not increase the risk of pre-existing GA progression. Therefore, cataract surgery seems safe and a potential therapeutic weapon to improve visual acuity and consequently quality of life in GA patients.

The Role of Atopy in the Choroidal Profile of Keratoconus Patients

Purpose

Although classically classified as a non-inflammatory condition, an inflammatory basis for keratoconus (KC) appears to be a growing evidence. Recently, it has been shown that KC patients have an increased choroidal thickness (CT). Among inflammatory disorders, atopy has been associated with KC development; therefore, the aim of this study was to evaluate if the increased CT in patients with KC is related to atopy.

Methods

This is an analytical cross-sectional study of patients with KC. Patients were classified as atopic and non-atopic according to their atopy history (allergic rhinoconjunctivitis (AR), asthma (AA) and/or atopic dermatitis (AD)) and were also classified based on their eye rubbing habits. Choroidal profile of all subjects was evaluated using a Spectralis optical coherence tomography (OCT) device with enhanced depth imaging (EDI) mode. CT was measured and compared between groups at the center of the fovea and at 500 µm intervals along a horizontal section. A multivariable analysis, adjusted for sex, age, spherical equivalent, history of medication and atopy, was performed to assess the influence of atopy in CT.

Results

Of the 80 patients included, 51 were atopic and 29 non-atopic. Atopic patients showed a thicker choroid in every measured location than the non-atopic patients (mean subfoveal CT 391.53 µm vs 351.17 µm, respectively), although the differences were not statistically different. The multivariable analysis revealed that being atopic makes the choroid statistically thicker, on average, 55.14 µm, when compared to non-atopic patients (p=0.043). Furthermore, patients who are frequent eye rubbers have significantly thicker choroids than non-rubbers (p=0.004).

Conclusion

Although some results do not reach statistical significance, atopic KC patients seem to have thicker choroids compared with non-atopic KC patients, suggesting a possible role for atopy in the choroidal profile of KC. This constitutes a completely new sight in this field of research that needs further investigation.

Orbital Apex Syndrome due to Orbital Mucormycosis after Teeth Infection: A Successful Case Report

Rhino-orbital-cerebral mucormycosis is a severe and rapidly progressive fungal infection associated with low survival rates. Early diagnosis and proper management are mandatory. We report the case of a 20-year-old female with diabetic ketoacidosis and teeth infection, who presented with sudden orbital apex syndrome. Several surgical procedures were necessary to provide a definite histopathological diagnosis of the fungal infection. Ultimately, given the progressive aggravation of the infection and the ineffectiveness of antifungal and antibiotic agents, an orbital exenteration was performed. A mycobacteriological examination revealed a polymicrobial culture with Mucorales. One year after the initial presentation, the patient is alive and with a good general health condition.

Childhood-Onset Leber Hereditary Optic Neuropathy: Particular Features

Background

Leber hereditary optic neuropathy (LHON) is an optic neuropathy of mitochondrial inheritance. Childhood-onset disease is relatively rare and there are limited data on this important patient subgroup.

Case Presentation

We present 3 particular presentations of LHON. Patient 1 was an 8-year-old boy admitted to the emergency department reporting a progressive bilateral visual loss and intermittent headaches. Neuro-ophthalmological examination revealed a bilateral pseudopapilledema. Lumbar puncture identified intracranial hypertension and the brain and orbits magnetic resonance imaging showed T2 hyperintensity in the posterior region of the left optic nerve and the optic chiasm. Patient 2 was a 12-year-old boy admitted to the emergency department reporting painless, progressive central vision loss in the right eye. Fundus examination revealed a hyperemic disc and vascular network papillary and peripapillary vascular microdilations. Three months later, the left eye presented visual loss. Patient 3 was a 6-year-old female child referred to the neuro-ophthalmology specialist due to painless central visual loss in both eyes. Her BCVA was 1/10 and counting fingers in right and left eye, respectively, and fundus examination revealed a pallor optic disc in the temporal sector.

Discussion

The phenotype of childhood-onset disease may present itself distinct from classical adult-onset LHON. The absence of classical clinical features could lead to initial misdiagnosis. There should exist a high index of suspicion in children presenting unexplained subnormal vision in order to avoid potential diagnostic delays.

Cone dystrophy with supernormal rod responses: A rare KCNV2 gene variant

PURPOSE

To describe the clinical, electrophysiological, and genetic findings of three Portuguese families with a rare variant in the KCNV2 gene resulting in "cone dystrophy with supernormal rod responses" (CDSRR).

METHODS

Retrospective clinical revision of five individuals from three unrelated families with CDSRR. Ophthalmological examination was described in all patients and included color vision testing, fundus photography, fundus autofluorescence (FAF) imaging, spectral domain-optical coherence tomography (SD-OCT), pattern electroretinogram (ERG), and full-field ERG. The mutational screening of the KCNV2 gene was performed with Sanger and Next Generation Sequencing.

RESULTS

All patients showed childhood-onset photophobia and progressive visual acuity loss with varying degrees of severity. In multimodal imaging, various degrees of retinal pigment epithelium disturbances and outer retinal atrophy, which tend to be worst with advancing age, were observed. Molecular screening identified a rare presumed truncating variant (p.Glu209Ter) in homozygosity in two families and in compound heterozygosity in a third family. Three patients showed ERG changes characteristic of CDSRR, however, two patients presented with incomplete electrophysiological features of the disease.

CONCLUSION

A rare variant in the KCNV2 gene was identified in five patients from three Portuguese families. This variant often leads to a severe and progressive form of retinopathy. Considerable variability in the ERG responses among patients with this KCNV2 variant was observed.

Predicting retinal pigment epithelium remodelling and its functional impact

PURPOSE

To identify predictive factors for RPE tear remodelling and its correlation with functional and morphological outcomes.

METHODS

Retrospective longitudinal study of patients with retinal pigment epithelium (RPE) tears secondary to age-related macular degeneration (AMD). Imaging was performed using spectral-domain optical coherence tomography (SD-OCT) and fundus autofluorescence (FAF). RPE layer integrity in the RPE-denuded area was examined with SD-OCT, and variation in the RPE-denuded homogeneous hypofluorescent area was examined with FAF over time for each case (eye). Patients were divided in two groups, according to the presence (Rem) or absence (No Rem) of evidence of RPE tear remodelling. Data were collected at three different time points: at baseline (at diagnosis of exudative AMD), at RPE tear diagnosis, and at the last available follow-up. Using SD-OCT, the following parameters were evaluated: type of CNV, type of PED and its dimensions, presence of subretinal (SRF) or intraretinal (IRF) fluid, central retinal thickness (CRT), presence and location of hyperreflective dots, and dimension and location of RPE tear.

RESULTS

This study included 32 eyes from 31 patients (19 female and 12 male), with RPE tears secondary to AMD. RPE remodelling after tear development was evident in 17 (53.1%) eyes after 7 [1-59] months. Anatomical recovery was associated with a younger age at RPE tear diagnosis (73 ± 7 vs. 81 ± 7 years old, p=0.01), smaller and narrower retinal pigment epithelial detachment (PED) at tear diagnosis (height 369 vs. 602 μm, p=0.02; width 2379 vs. 3378 μm, p=0.04), and the presence of SRF at tear diagnosis (94% vs. 53%, p=0.02). After adjusting for other covariates, a younger age at RPE tear diagnosis maintained significant association with RPE tear remodelling. RPE tear remodelling did not correlate with a better visual outcome at last follow-up (43 ± 22.8 vs. 34 ± 23.8 ETDRS letters, p=0.30). Final VA was directly proportional to VA at tear diagnosis (r= 0.654; p<0.001) and correlated negatively with PED width at tear diagnosis (r = -0.388; p=0.03).

CONCLUSION

RPE remodelling was evident in half of our sample and was associated with a younger age, smaller and narrower PED at RPE tear diagnosis, and presence of SRF also at tear diagnosis. Nevertheless, this structural recovery did not result in a better functional outcome.

Long term outer retinal changes in central serous chorioretinopathy submitted to half-dose photodynamic therapy

PURPOSE

To evaluate long-term changes in the foveal and parafoveal outer retina after half-dose photodynamic therapy (HD-PDT) in central serous chorioretinopathy (CSC).

METHODS

Retrospective study including CSC patients submitted to HD-PDT. Best corrected visual acuity (BCVA) was evaluated. Spectral-domain optical coherence tomography automatic segmentation algorithm was used and data on retinal, inner retinal, outer retinal and outer nuclear layers (ONL) in both foveal 1 mm (C) and parafoveal 3 mm ETDRS circles for the superior, nasal, inferior and temporal sectors, were obtained at baseline and 3, 12 and 24 months post-treatment. Subfoveal choroidal thickness, photoreceptors' outer segment thickness, subretinal fluid (SRF) height and width were also measured.

RESULTS

Twenty-one eyes of 15 patients were included. At baseline, the mean ONL thickness in the foveal area was significantly thinner in affected eyes compared to their fellow unaffected ones (55,50 ± 32,75 μm vs 93,00 ± 17,0 μm; p = 0,011), and was negatively correlated to logMAR BCVA (R=-0,601, p = 0,008) ONL thickness increased by 10,94 ± 11,88 μm at 24 months in the foveal area, and all the parafoveal sectors presented a similar increase. Baseline SRF width was significantly correlated with baseline BCVA (R1 = 0,483, p = 0,036), and with ONL thickness in all sectors.

CONCLUSION

In our study we found a significant long-term increase in foveal and parafoveal ONL thickness in CSC after HD-PDT, suggesting that this seems to be a safe treatment for the outer retina. This is the first study mapping the outer retinal changes in the macular area to 24 months follow up.

Epidemiology of Uveitis in a tertiary care centre in Portugal

Purpose: Evaluate the prevalence and incidence, demographic characteristics, anatomical classification, concomitant complications and treatment of uveitis, as well as its association with systemic diseases in the northern Portuguese population referred to a tertiary care centre (São João Hospital, Porto).Methods: A retrospective observational study of 545 consecutive uveitis cases was performed between 12th April 2012 and the 26th October 2017. Uveitis was classified according to Standard Uveitis Nomenclature, while aetiology and complications were diagnosed by specific clinical and laboratory testing.Results: Prevalence was calculated to be 12,4 cases per 100,000 people while incidence was 3.9 cases per 100,000 people annual incidence. The ratio of females to males was 1.32:1 and the mean age at diagnosis was 47,86 years. Anterior uveitis was the most common classification making up 47.5%, followed by non-infectious posterior uveitis 18,0%, infectious posterior uveitis 8,4%, intermediate uveitis 5,5% and panuveitis 4,2%. Extra-uveal entities made up the rest of the causes (16.4%). In terms of aetiology, the majority of uveitis was idiopathic (32,1%) followed by axial spondylarthritis (12.1%), Behçet's disease (8,8%), sarcoidosis (6,1%), tuberculosis (5,5%), herpes (5,1%), toxoplasmosis (3,1%) among other less frequent causes.Conclusion: In our referral region, 72% of uveitis cases were correctly identified surpassing other studies. There was a higher rate of intermediate uveitis and lower number of panuveitis cases when compared to a previous Portuguese study. Extensive monitoring of the development of uveitis by international multicentre prospective studies could be useful for increasing practitioner awareness and diagnostic approach.

Child with a mild phenotype of Incontinentia Pigmenti and inner retinal dysfunction

PURPOSE

To describe a case of a child with mild phenotype of Incontinentia Pigmenti (IP), with changes in Spectral-Domain Optical Coherence Tomography (SD-OCT) and Optical Coherence Tomography Angiography (OCT-A) and an electronegative dark-adapted (DA) 3.0 electroretinogram (ERG), suggestive of inner retinal dysfunction.

CASE REPORT

We described a 7-year-old female child with IP. Her best corrected acuity was 8/10 in the right eye and 6/10 in the left eye. Biomicroscopy, intraocular pressure and fundoscopy were normal. The electroretinography findings showed an electronegative DA 3.0 ERG with a normal a-wave but a b-wave that did not elevate above baseline. SD-OCT identified irregularities in the outer plexiform layer in both eyes, and OCT-A assessment revealed at the superficial capillary plexus, areas of decrease in the flow in parafoveal and perifoveal regions.

CONCLUSION

Classically, IP affects the peripheral retina; however, vascular and structural changes in macula can occur as well. To our knowledge, we report the first electronegative electroretinogram in a patient with IP.

Increased choroidal thickness is not a disease progression marker in keratoconus

The recent findings of increased Choroidal Thickness (CT) in Keratoconus (KC) patients raised the question of whether CT could be an indicator of progressive KC. To test this hypothesis, we evaluated and compared the choroidal profile in progressive and non-progressive KC. We ran a cross-sectional observational study in 76 patients diagnosed with KC, age 14–30, to assess KC progression. Progression was defined as when at least two of the studied variables confirmed progression (Kmax, Km, PachyMin, D-Index, Astig, K2, 3 mm PCR). Included patients performed a Spectralis Optical Coherence Tomography (OCT) with enhanced depth image (EDI) technology to evaluate choroidal profile. Choroidal measurements were taken subfoveally and at 500 µm intervals from the fovea, in 7 different locations, and compared between groups. Multivariate linear regression analyses were also performed to assess the influence of CT in KC progression. Thirty-six eyes (47.4%) were classified as KC progressors. The mean subfoveal CT observed in the total sample was 382.0 (± 97.0) μm. The comparison between groups (progressive and non-progressive KC) showed no differences in the locations evaluated (mean subfoveal CT difference between groups was 2.4 μm, p = 0.915). In the multivariate analysis CT seems not be influenced by KC progression (B = 6.72 μm, 95% CI − 40.09 to 53.53, p = 0.775). Assessment of choroidal profile does not appear to be a useful tool to differentiate progressive and non-progressive KC. Further research is needed in order to better understand the role of choroid in KC.

A 10-Year Retrospective Clinical Analysis of Fungal Keratitis in a Portuguese Tertiary Centre

Purpose

To determine the microbiological profile, risk factors, treatment and surgical intervention rates of fungal keratitis at a tertiary referral centre.

Methods

A retrospective review of microbiological and medical records from hospitalised patients treated for fungal keratitis at Centro Hospitalar Universitário de São João from 2009 to 2019 was conducted.

Results

Overall, 43 patients were included in our study. The mean age of patients was 63.7 years and 46.5% were men. In culture were isolated 22 (51.2%) filamentous fungi and 21 (48.8%) yeast. Candida species (n = 20, 46.5%), Fusarium species (n = 10, 23.4%) and Aspergillus species (n = 4, 9.3%) were the most common isolated species. Important risk factors were contact lens use (n = 24, 55.8%), long-term users of topical corticosteroids (n = 19, 44.2%) and previous keratitis (n = 19, 44.2%). Yeast isolates had a statistically significant higher prevalence in long-term users of topical corticosteroids compared to filamentous ones (p = 0.043). Twenty-four cases (55.8%) required surgical intervention, of which 23 cases underwent therapeutic penetrating keratoplasty. Ocular complications, such as evisceration was noted in 12 patients (27.9%) and endophthalmitis in 5 (11.6%). No statistically significant changes of best corrected visual acuity (BCVA) were found after treatment (p = 0.687).

Conclusion

Most patients with fungal keratitis have associated risk factors. Filamentous and yeast species have equally prevalent etiologies. In general, our results mirror how difficult and challenging the approach and treatment of fungal keratitis could be.

The Relationship between Intraocular Pressure and Optic Nerve Structural and Functional Damage in Patients with Optic Nerve Head Drusen

The aim of this retrospective study was to evaluate if, in ocular normotensive patients, at the time of diagnosis of optic nerve head drusen (ONHD), perimetric mean deviation (PMD) on visual field (VF) examination and retinal nerve fibre layer (RNFL) thickness on optical coherence tomography correlated with intraocular pressure (IOP). There was a significant association between IOP and PMD (Spearman's rho = -0.863, p < .01) and between IOP and RNFL thickness (Spearman's rho = -0.630, p < .01). A higher IOP was associated with a greater functional loss in the VF and a reduction in the RNFL thickness. These results suggest that a clinical trial of IOP reduction should be considered in patients with ONHD to decrease the progression of optic nerve damage over time.

Longitudinal Retinal Changes Induced by Hydroxychloroquine in Eyes without Retinal Toxicity

INTRODUCTION

This study aimed to evaluate the longitudinal changes in retinal layer thickness in patients treated with hydroxychloroquine without retinal toxicity.

METHODS

This is a longitudinal retrospective study of patients taking hydroxychloroquine followed in a hydroxychloroquine retinal toxicity screening program of a tertiary hospital between January 2010 and April 2019. Patients who performed 2 optical coherence tomography (OCT) scans at least 1 year apart were included. All subjects with hydroxychloroquine suspected or confirmed retinal toxicity, glaucoma, retinal pathology, or poor segmented images were excluded. Spectral-domain optical coherence tomography (Spectralis HRA-OCT, Heidelberg) was used to evaluate the macular area. Automatically segmented ETDRS retinal thickness maps were compared between the first and the last OCT evaluation available. Full retina (FR), inner retina (IRL), ganglion cells (GCL), inner nuclear (INL), and outer retina (ORL) layer thicknesses were measured in the foveolar, paracentral, and peripheral area.

RESULTS

The population included 144 eyes of 144 patients. The mean interval between OCT scans was 38.1 ± 18.4 months, and the mean cumulative dose was 406.9 ± 223.9 g. Foveolar (p = 0.040, p = 0.006, and p = 0.001, respectively) and paracentral (p = 0.006, p = 0.001, and p = 0.005, respectively) FR, IRL, and GCL decreased overtime. No differences were found in INL or ORL. A very weak correlation was found between age and foveal IRL change overtime (p = 0.037; R = 0.175), as well as between the hydroxychloroquine time of use and foveal GCL variation (p = 0.032; R = 0.179).

CONCLUSION

Hydroxychloroquine was found to cause progressive thinning of the inner retinal layers, specifically in the GCL of the foveolar and paracentral areas, but no changes were observed in the outer retina.

SARS-COV-2 in Ophthalmology: Current Evidence and Standards for Clinical Practice

INTRODUCTION

COVID-19 is caused by the coronavirus SARS-CoV-2. Ocular manifestations have been reported including conjunctivitis and retinal changes. Therefore, it is of the utmost importance to clarify eye involvement in COVID-19 in order to help with its diagnosis and to further prevent its transmission. The purpose of this review is to describe the structure and transmission of SARS-CoV-2, reported ocular findings and protection strategies for ophthalmologists.

MATERIAL AND METHODS

Literature search on PubMed for relevant articles using the keywords 'COVID-19', 'coronavirus', and 'SARS-CoV-2' in conjunction with 'ophthalmology' and 'eye'. Moreover, official recommendations of ophthalmological societies were reviewed.

RESULTS

Although the conjunctiva is directly exposed to extraocular pathogens, and the mucosa of the ocular surface and upper respiratory tract are connected by the nasolacrimal duct, the eye is rarely involved in human SARS-CoV-2 infection and the SARS-CoV-2 RNA positive rate by RT-PCR test in tears and conjunctival secretions from patients with COVID-19 is also extremely low.

DISCUSSION

The eye can be affected by SARS-CoV-2, which is supported by some reports of conjunctivitis and retinal changes, but its role in the spread of the disease is still unknown.

CONCLUSION

Given the current scarce evidence, more research is needed to clarify the relationship between SARS-CoV-2 and the eye.

Transepithelial Accelerated Corneal Collagen Cross-Linking: Two-Year Results

PURPOSE

To report 2-year outcomes of trans-epithelial accelerated corneal collagen crosslinking (TE-ACXL) procedure in the treatment of progressive keratoconus patients.

PATIENTS AND METHODS

Twenty-four eyes from 24 patients who underwent TE-ACXL (6mW/cm2 for 15 minutes) were included in this retrospective interventional study. Best-corrected visual acuity (BCVA), keratometry values, thinnest corneal thickness (PachyMin) and topometric indexes were analysed preoperatively and at 6-month, 12-month, 18-month and 24-month postoperative. Progression was assessed by increase ≥1.00D in maximum keratometry (Kmax); increase ≥1.00D in corneal astigmatism; decrease ≥2% in PachyMin; increase ≥0.42 in D-index.

RESULTS

There were no complications during or after TE-ACXL. No significant differences (Δ) were observed between baseline and 12-month or 24-month postoperative: ∆BCVA (-0.08 ± 0.25, p=0.190; -0.04 ± 0.17, p=0.588), ∆Kmax (-0.08 ± 1.32, p=0.792; -1.04 ± 1.89, p=0.135), ∆Astigmatism (-0.15 ± 0.89, p=0.485; -0.24 ± 1.38, p=0.609), ∆PachyMin (-0.56 ± 15.70, p=0.882; 0.56 ± 18.74, p=0.931), ∆Index Surface Variation (∆ISV) (-2.11 ± 10.27, p=0.395; -4.67 ± 17.32, p=0.442), ∆Index Vertical Asymmetry (∆IVA) (-0.05 ± 0.17, p=0.208; -0.08 ± 0.26, p=0.397), ∆Index Height Decentration (∆IHD) (0.00 ± 0.02, p=0.368; -0.01 ± 0.04, p=0.484), ∆KI (0.00 ± 0.05, p=0.851; 0.01 ± 0.06, p=0.877) and ∆D-index (0.15 ± 1.14, p=0.572; 0.06 ± 1.36, p=0.892). Eleven to 33% of patients had disease progression at 24-month postoperative according to the parameters used to determine progression.

CONCLUSION

Although some patients maintain disease progression, TE-ACXL seems to be a safe and effective treatment for keratoconus over the 2-year follow-up period. Studies with longer follow-up periods and larger patient cohorts are recommended.

Bariatric Surgery Induces Retinal Thickening Without Affecting the Retinal Nerve Fiber Layer Independent of Diabetic Status

PURPOSE

Obese patients have neurodegeneration of the optic nerve demonstrated by decreased peripapillary nerve fiber layer. Whether bariatric surgery reverses this neurodegenerative process has not been explored. We aimed to evaluate the impact of bariatric surgery in the structure of the retina and optic nerve.

METHODS

Multicentric observational study. Obese patients scheduled for bariatric surgery were consecutively recruited and included in the study and evaluated before and 6-12 months after the intervention. The retinal structure was evaluated as retinal thickness in the different retinal layers in the foveal, perifoveal, and parafoveal regions using optical coherence tomography. Choroidal thickness and optic nerve retinal nerve fiber layer thickness were also evaluated.

RESULTS

Eighty eyes from 40 participants were included. Globally, we found a significant thickening of the retina after bariatric surgery (foveal: 273.5 (21.5) μm vs 280.0 (28.8) μm, p < 0.001; parafoveal 332.4 ± 17.8 μm vs 336.6 ± 15.9 μm, p = 0.003; perifoveal: 293.4 ± 13.8 μm vs 295.7 ± 14.9 μm; p = 0.001), whereas no significant differences were found for the ganglion cell layer, choroid, or peripapillary nerve fiber layer thickness. The retinal thickening was confined to inner retinal layers and was independent of the diabetic status of the patients. After multivariate adjustment, HbA1c variation, preoperative C-peptide, preoperative hypertension, preoperative OSA, and preoperative LDL and TG levels seem to be clinical predictors of retinal thickening.

CONCLUSIONS

We found a significant thickening of the retina after bariatric surgery that was independent of the diabetic status. The thickening was confined to inner retinal layers and may represent and improve perfusion. The peripapillary nerve fiber layer remained unchanged after the surgery.