HAIR TRANSPLANTATION COMPLICATED BY METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS SEPSIS AND ENDOGENOUS ENDOPHTHALMITIS

PURPOSE

To describe a case of endogenous endophthalmitis as a complication from hair transplantation.

METHODS

Case report of a 53-year-old man with a history of recent hair transplantation.

RESULTS

The patient presented with a febrile illness and blurry vision 1 week after hair transplantation. Infectious workup included blood cultures positive for methicillin-resistant Staphylococcus aureus, and he was treated with IV antibiotics. Initial ocular examination demonstrated 20/30 and hand motions in the right and left eyes, respectively, with significant vitritis. He underwent vitreous tap and injections of vancomycin and dexamethasone in both eyes and removal of purulent staple from the site of recently transplanted hair. His ocular and systemic symptoms improved. Approximately 3 months after initial clearing of the initial infection he had recurrence of bacteremia that prompted repeat intravitreal and systemic antibiotics. His vision returned to baseline with mild residual optic nerve pallor and atrophic retinal changes in the left eye.

CONCLUSION

Hair transplantation is associated with minimal systemic complications, but in rare cases, sepsis is possible and can result in intraocular seeding causing endophthalmitis. MRSA endogenous endophthalmitis frequently results in negative vitreous taps and treatment outcomes in the literature have been shown to vary widely including a return to baseline vision as in the described case.

Postoperative Inflammation After Anterior Segment Surgery

A 71-year-old woman had 2 months of worsening vision and pain in her right eye. Examination revealed retrocorneal plaque, peaking of the pupil, and temporal prominent scleral vessels with inferotemporal scleral thinning. What would you do next?

Association of Cutaneous Keloids, Hypertrophic Scarring, and Fibrosis with Risk of Postoperative Proliferative Vitreoretinopathy

PURPOSE

To assess an association between cutaneous keloids, hypertrophic scarring, and fibrosis (KHF) and risk of postoperative proliferative vitreoretinopathy (PVR) after rhegmatogenous retinal detachment (RRD) repair.

DESIGN

Retrospective, population-based cohort study.

PARTICIPANTS

Patients aged ≥ 18 years who underwent initial retinal detachment (RD) repair with pars plana vitrectomy with or without scleral buckle (SB) (Current Procedural Terminology [CPT] 67108), pneumatic retinopexy (67110), and primary SB (67107) from January 1, 2003, to March 1, 2023.

METHODS

A de-identified electronic health record database through TriNetX, a global health research network, was used to analyze patients. Patients were queried for International Classification of Diseases, 10th Revision (ICD-10) codes L91.0 (hypertrophic scar) and L90.5 (scar conditions and fibrosis of skin). Frequency of subsequent diagnosis of PVR (H35.2) and CPT codes for secondary surgery including complex RD repair (67113) were determined. Patients with proliferative diabetic retinopathy (PDR) (ICD-10 H10.35/H11.35) were excluded. Descriptive statistics (Z-test) and propensity score matching (PSM) were used to match for age, sex, and race.

MAIN OUTCOME MEASURES

Prevalence of H35.2 and CPT 67113 within 180 days after RRD repair in the KHF cohort versus the non-KHF cohort.

RESULTS

Among patients with CPT 67108, 1061 in each cohort (KHF and non-KHF) were analyzed after PSM. The mean (standard deviation) age was 60.7 (15.2) years. Within 180 days, 10.1% of patients in the KHF cohort and 3.4% in the non-KHF cohort had a diagnosis of PVR (H35.2) (P < 0.001, odds ratio [OR], 3.2; 95% confidence interval [CI], 2.13-4.71). A total of 8.3% of patients in the KHF cohort and 5.4% of patients in the non-KHF cohort underwent complex RD repair (CPT 67113) (P = 0.008; OR, 3.2; 95% CI, 1.13-2.25). When including all RD repair types (CPT 67108, 67110, 67107), the rate of PVR diagnosis was still significantly greater in the KHF cohort than in the non-KHF cohort (9.0% vs 4.2%, P < 0.01; OR, 2.28; 95% CI, 1.64-3.16).

CONCLUSIONS

A dermatologic history of KHF may be a risk factor for PVR after RD repair.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Short-Term Outcomes of Faricimab in Patients with Neovascular Age-Related Macular Degeneration on Prior Anti-VEGF Therapy

PURPOSE

A subset of patients with neovascular age-related macular degeneration (nAMD) experience treatment burden and suboptimal response with anti-VEGF therapy. The aim of this study was to investigate the effect of switching to a novel, bispecific agent, faricimab, in patients with nAMD currently treated with anti-VEGF.

DESIGN

Retrospective, noncomparative cohort study.

SUBJECTS

Patients with nAMD previously treated with anti-VEGF and switched to intravitreal faricimab injection (IFI) at the Cleveland Clinic's Cole Eye Institute.

METHODS

Switching and administration schedule of IFI was at the discretion of the clinician. Visual acuity (VA) and macular OCT parameters, including central subfield thickness (CST), maximum pigment epithelial detachment (PED) height, and presence of subretinal (SRF) or intraretinal fluid (IRF), were assessed at baseline (day of first IFI) and after each IFI.

MAIN OUTCOME MEASURES

Central subfield thickness and presence of IRF or SRF after ≥ 3 IFIs.

RESULTS

One hundred twenty-six eyes of 106 patients were included in the analysis with a mean follow-up time of 24.3 ± 5.2 weeks. Before switching to IFI, patients received a mean of either aflibercept (20.0 ± 8.4, mean ± standard deviation), bevacizumab (7 ± 8.9), ranibizumab (1.9 ± 8.5), or brolucizumab (0.3 ± 1.6) injections. The most common agent used before switching to IFI was aflibercept (n = 110, 87%), and the mean treatment interval with any anti-VEGF was 5.6 ± 1.6 weeks before switching. Central subfield thickness was reduced from baseline after the first IFI (266.8 ± 64.7 vs. 249.8 ± 58.6 μm, P = 0.02) and persisted over the 3 IFIs (P = 0.01). Pigment epithelial detachment height was reduced after the third IFI (249.6 ± 179.0 vs. 206.9 ± 130.0 μm, P = 0.01). The mean VA (62.9 vs. 62.7 approximate ETDRS letters, P = 0.42) and interval between injections (6.3 vs. 5.7 weeks, P = 0.16) was similar after the third IFI compared with baseline. Eleven (8.7%) eyes were switched back to their previous anti-VEGF, including 2 (1.6%) eyes from 1 patient with intraocular inflammation requiring cessation of IFI. There were no other adverse events from switching.

CONCLUSIONS

Switching to faricimab resulted in a reduction in mean CST (-11.6 μm, P = 0.01) and PED height (-44.2 μm, P = 0.01) after 3 injections, with stable VA and at a similar treatment interval to prior anti-VEGF therapy.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Bacillary Layer Detachment as a Presenting Feature of Ocular Sarcoidosis

BACKGROUND AND OBJECTIVE

Bacillary layer detachment (BALAD) is a recently described finding on optical coherence tomography (OCT) that has been reported in a variety of uveitic and retinal diseases. To add to the growing literature on conditions associated with this finding, we report on the first cases of BALADs in ocular sarcoidosis.

PATIENTS AND METHODS

Observational, retrospective chart review of patients with BALADs as a feature of sarcoid-associated uveitis.

RESULTS

Three patients presented with blurry vision and bacillary layer detachments on OCT who were either known to have or found to have sarcoid-associated uveitis. All three patients had resolution of the BALAD and improvement in visual acuity with a combination of high-dose oral steroids and/or systemic immunosuppression.

CONCLUSIONS

Patients presenting with BALAD should be assessed for sarcoidosis, if appropriate, given the systemic implications of this diagnosis. [Ophthalmic Surg Lasers Imaging Retina 2023;54:686-690.].

Fungal Endophthalmitis Secondary to Aspergillus terreus Exacerbated by Intravitreal Dexamethasone in a Patient With Sarcoidosis

Purpose: To report a case of Aspergillus terreus endophthalmitis associated with systemic immunosuppression and an intraocular steroid implant in a patient with sarcoidosis. Methods: A case report was evaluated and a literature review performed. Results: A patient with a history of pulmonary and ocular sarcoidosis presented with new-onset uveitis and was treated for presumed sarcoid flare with oral prednisone and an intravitreal dexamethasone implant before developing worsening vision. She was ultimately diagnosed with A terreus endophthalmitis. Despite both systemic and local antifungals, the visual acuity at the most recent follow-up was no light perception without pain or active inflammation. No definitive source of the fungal disease had been identified. Conclusions: Endophthalmitis resulting from A terreus is associated with poor outcomes. Given the ability of fungal endophthalmitis to mimic other causes of uveitis, one must maintain a high suspicion in patients with any degree of immunosuppression.

Evaluation and Comparison of Ophthalmic Scientific Abstracts and References by Current Artificial Intelligence Chatbots

Importance

Language-learning model-based artificial intelligence (AI) chatbots are growing in popularity and have significant implications for both patient education and academia. Drawbacks of using AI chatbots in generating scientific abstracts and reference lists, including inaccurate content coming from hallucinations (ie, AI-generated output that deviates from its training data), have not been fully explored.

Objective

To evaluate and compare the quality of ophthalmic scientific abstracts and references generated by earlier and updated versions of a popular AI chatbot.

Design, Setting, and Participants

This cross-sectional comparative study used 2 versions of an AI chatbot to generate scientific abstracts and 10 references for clinical research questions across 7 ophthalmology subspecialties. The abstracts were graded by 2 authors using modified DISCERN criteria and performance evaluation scores.

Main Outcome and Measures

Scores for the chatbot-generated abstracts were compared using the t test. Abstracts were also evaluated by 2 AI output detectors. A hallucination rate for unverifiable references generated by the earlier and updated versions of the chatbot was calculated and compared.

Results

The mean modified AI-DISCERN scores for the chatbot-generated abstracts were 35.9 and 38.1 (maximum of 50) for the earlier and updated versions, respectively (P = .30). Using the 2 AI output detectors, the mean fake scores (with a score of 100% meaning generated by AI) for the earlier and updated chatbot-generated abstracts were 65.4% and 10.8%, respectively (P = .01), for one detector and were 69.5% and 42.7% (P = .17) for the second detector. The mean hallucination rates for nonverifiable references generated by the earlier and updated versions were 33% and 29% (P = .74).

Conclusions and Relevance

Both versions of the chatbot generated average-quality abstracts. There was a high hallucination rate of generating fake references, and caution should be used when using these AI resources for health education or academic purposes.

Vitreoretinal lymphoma with central nervous system involvement in a patient with sarcoidosis: a case report

PURPOSE

To describe a case of primary vitreoretinal lymphoma with central nervous system involvement in a patient with sarcoidosis.

METHODS

Single, retrospective chart review.

PATIENT

A 59-year-old male with sarcoidosis.

RESULTS

The patient presented with a 3-year history of bilateral panuveitis thought secondary to his sarcoidosis diagnosed 11 years prior. Shortly before presentation, the patient demonstrated recurrent uveitis with a lack of response to aggressive immunosuppression therapy. At presentation, ocular exam showed significant anterior and posterior inflammation. Fluorescein angiography demonstrated hyperfluorescence of the optic nerve with late and small vessel leakage in the right eye. The patient also described a two-month history of memory and word-finding deficits. An inflammatory and infectious disease work-up was unremarkable. A brain MRI showed multiple enhancing periventricular lesions with vasogenic edema, while a lumbar puncture was negative for malignant cells. A diagnostic pars plana vitrectomy confirmed a diagnosis of large B-cell lymphoma.

CONCLUSION

Sarcoidosis and vitreoretinal lymphoma are known masqueraders. Recurrent inflammation typical of sarcoid uveitis may mask a more sinister diagnosis such as vitreoretinal lymphoma. Furthermore, sarcoid uveitis treatment with corticosteroids may transiently improve symptoms but further delay a timely diagnosis of primary vitreoretinal lymphoma.

Coats Plus Syndrome in a Premature Infant, With a Focus on Management

Purpose

A premature infant was diagnosed with Coats plus syndrome based on a genetic evaluation showing biallelic heterozygous pathogenic CTC1 variants.

Methods

A case study was performed, including findings and interventions.

Results

A premature infant born 30 weeks gestational age weighing 817 g was evaluated for retinopathy of prematurity at 35 weeks corrected gestational age. An initial dilated fundus examination showed an exudative retinal detachment (RD) in the right eye and avascularity post-equatorially in the left eye with telangiectasias and aneurysmal dilations. Genetic evaluation showed biallelic heterozygous pathogenic CTC1 variants, diagnostic of Coats plus syndrome. Sequential examination under anesthesia with fluorescein showed progressive ischemia despite confluent photocoagulation.

Conclusions

CTC1 gene variants manifest as Coats plus syndrome, which has a clinical appearance consistent with retinovascular ischemia, capillary remodeling, aneurysmal dilation, and exudative RD. Systemic and local corticosteroids in conjunction with peripheral laser ablation decreased vascular exudation and avoided intraocular intervention.

Vision health perspectives on Breaking Bad: Ophthalmic sequelae of methamphetamine use disorder

Methamphetamine use has become a rampant public health issue that not only causes devastating consequences to the user but also poses a burden to surrounding communities. A spectrum of ophthalmic sequelae is associated with methamphetamine use and includes episcleritis, scleritis, corneal ulceration, panophthalmitis, endophthalmitis, retinal vasculitis, and retinopathy. In many instances, prompt recognition of the condition and associated infectious process and early initiation of antimicrobial therapy are crucial steps to preventing vision loss. In this review, we summarize the reported ocular complications that may result from methamphetamine use in addition to several postulated mechanisms regarding the ocular toxicity of methamphetamine. The increasing prevalence of methamphetamine use as a public health threat highlights the need for continued investigation of this ophthalmologic issue.

Primary ocular toxoplasmosis secondary to venison consumption

Purpose

To describe primary ocular toxoplasmosis infection related to ingestion of undercooked venison.

Observations

This single site, retrospective case series reviewed 4 patients with primary ocular toxoplasmosis that was acquired by ingesting undercooked venison. De-identified data was collected regarding baseline patient characteristics including age, sex, past medical and ocular history, onset of symptoms, visual acuity (VA), response to treatment, and workup. All patients with acquired toxoplasmosis had similar chronology of systemic and ocular symptoms. Exposure occurred in October or November and systemic symptoms developed within 2 weeks, followed by ocular symptoms an average of 2.6 months later. Average age at onset was 56 ± 13 (age ± SD) years old and all were male. Average initial and final VA were 20/50 and 20/50, respectively. Positive anti-toxoplasma IgM and IgG serologies were found in all cases. All patients were treated with trimethoprim/sulfamethoxazole and achieved rapid improvement. Complications occurred in 50% of cases and included epiretinal membrane, cystoid macular edema, vitreoretinal traction, and neovascularization.

Conclusions and importance

Consumption of undercooked venison is a source of primary ocular toxoplasmosis even in immunocompetent hosts and has a clear chronology. A presentation of retinochoroiditis during the winter months should prompt questioning for exposure to wild game.

Visual, Anatomic Outcomes, and Natural History of Retinal Nerve Fiber Layer Schisis in Patients Undergoing Epiretinal Membrane Surgery

PURPOSE

To evaluate the anatomic and visual outcomes of patients with idiopathic epiretinal membranes (ERMs) complicated by schisis of the retinal nerve fiber layer (sRNFL) in routine clinical practice.

DESIGN

Retrospective case-control study.

PARTICIPANTS

Patients undergoing idiopathic ERM surgery at Cole Eye Institute from 2013 to 2021.

METHODS

Patients were grouped by the presence or absence of sRNFL before surgery. Preoperative and postoperative data were collected regarding visual acuity (VA), changes in central subfield thickness (CST) over time, and presence of cystoid macular edema.

MAIN OUTCOME MEASURES

Frequency of sRNFL in patients undergoing idiopathic ERM surgery.

RESULTS

Overall, 48 (53.9%) of 89 patients presented with sRNFL. Schisis of the retinal nerve fiber layer patients presented with significantly decreased VA compared with those without (58.63 ± 12.48 vs. 67.68 ± 7.84 ETDRS letters, P < 0.001, respectively). At the final follow-up after ERM removal, there was no significant difference in final VA in patients with sRNFL compared with those without (71.16 ± 2.93 vs. 74.11 ± 2.76, P = 0.467). At presentation, patients with sRNFL had greater CST than those without (454 ± 10.01 vs. 436 ± 0.23, P = 0.23). This difference persisted at the 90-day follow-up after ERM removal (402 ± 8.08 vs. 375 ± 10.19 μm, P = 0.043). The resolution of sRNFL was reported at postoperative week 1 in 30 (96.7%) of 31 cases.

CONCLUSIONS

Schisis of the retinal nerve fiber layer is a microstructural feature in > 50% of idiopathic ERMs in routine clinical practice and carries visual significance on presentation and anatomic significance postoperatively.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Progression to Vision-Threatening Retinopathy Complications Following Panretinal Laser for Proliferative Diabetic Retinopathy

BACKGROUND AND OBJECTIVE

To report the time in which patients with panretinal photocoagulation (PDR) progress to vision-threatening retinopathy (VTR) complications after receiving PRP, and risk factors in routine clinical practice.

PATIENTS AND METHODS

Records of patients with complete PRP for PDR were retrospectively reviewed for up to 3.5 years after PRP. Two hundred twenty eyes were selected.

RESULTS

Time from PRP to VTR was 1.25 ± 0.82 years. Age, Black race, neovascularization of the disc on examination, diabetic foot disease (DFD), and high-risk PDR characteristics on fluorescein angiography were identified as significant risk factors. Half of patients with DFD on examination developed a VTR within 1.5 years after PRP (P < .001).

CONCLUSION

In clinical practice, providers may consider DFD and Black race as predictors of time to VTR event within 4 years after PRP in patients with PDR. [Ophthalmic Surg Lasers Imaging Retina. 2022;53(4):186-193.].

Ocular Syphilis With Phlebitis and Paravenous Pigmentary Retinopathy

Purpose:

Ocular syphilis can present as a wide variety of clinical phenotypes, among them panuveitis with vasculitis. Primary retinal phlebitis with resulting paravenous atrophy and pigmentary retinal degeneration is a rare presentation.

Methods:

A 53-year-old man presented with a 1-year history of bilateral blurry vision. Physical examination demonstrated bilateral anterior chamber and vitreous cell with vitreous haze, hyperemic optic nerves, and atrophic-appearing retina. The left eye demonstrated a nasal area of perivenular vascular sheathing with adjacent retinal whitening. Ancillary testing demonstrated predominantly perivenular leakage involvement.

Results:

Uveitic workup was positive for syphilis and HIV. The patient was treated with antiretroviral therapy and intravenous penicillin G. He developed progressive paravenous pigmentary changes and atrophy.

Conclusions:

Syphilis can present with a wide variety of phenotypic manifestations and should also be considered in patients presenting with acute retinal phlebitis or paravenous atrophy in long-standing cases.

Macular Hole as a Complication Following Laser Photocoagulation for Retinopathy of Prematurity

Complications after laser photocoagulation for retinopathy of prematurity (ROP) are rare but do occur. To the best of our knowledge, we report a previously unreported case of a unilateral macular hole that developed after resolution of an exudative retinal detachment that resulted from laser photocoagulation for ROP. Confluent laser patterns in ROP in infants who have previously received intravitreal anti-vascular endothelial growth factor may result in adverse outcomes such as exudative retinal detachments. Even more rarely, a macular hole may develop. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:510-512.].

Anterior segment ischemia after laser for retinopathy of prematurity previously treated with antivascular endothelial growth factor

PURPOSE

To assess the risk of vision-threatening anterior segment ischemia (ASI) among retinopathy of prematurity (ROP) patients treated with anti-VEGF followed by laser photocoagulation.

METHODS

The medical records of all infants treated for threshold ROP with laser photocoagulation with and without prior anti-VEGF injections from January 1, 2002, through December 2018 at Mayo Clinic were retrospectively reviewed for the prevalence of vision-threatening ASI.

RESULTS

A total of 241 eyes of 122 infants were included. Mean gestational age was 25.1 weeks (range, 22.9-28.7); mean birth weight was 687.6 g (range, 360-1310 g). Of the 54 eyes (27 patients) treated with anti-VEGF prior to laser, 4 developed ASI (including corneal edema, cataracts, and choroidal effusion) compared with 2 of the 187 eyes (95 patients) treated with laser therapy alone (P = 0.008). Infants receiving both anti-VEGF and laser had a younger gestational age at birth (24.5 vs 25.3 weeks; P < 0.001) and lower birth weight (591.4 g vs 715.0 g; P < 0.001) than those who received laser alone. In multivariate analysis, early gestational age at birth was associated with development of ASI (P = 0.03); the association with anti-VEGF treatment (P = 0.07) fell short of statistical significance.

CONCLUSIONS

The prevalence of vision-threatening ASI was higher among infants treated with intravitreal anti-VEGF followed by laser compared to those treated with laser alone. Further investigation is warranted to confirm this finding and identify potential factors for decreasing the risk of ASI.

Clinical Characteristics of a Case Series of Ocular Syphilis With 3 Cases Requiring Multiple Vitrectomies After Late Diagnosis

Purpose:

This work describes the characteristics and unique features of ocular syphilis.

Methods:

Ten serologically proven cases of ocular syphilis were retrospectively analyzed.

Results:

Eighteen eyes of 10 patients were affected. Nine of 10 patients were male and the mean age was 58 years (range, 36-81 years). HIV antibody testing was positive in 3 patients (30%). Five cases were first diagnosed by an ophthalmologist. One patient presented with a syphilitic rash. The most common ocular findings were panuveitis (n = 6) and cystoid macular edema (n = 4). Ocular involvement was unilateral in 2 cases and bilateral in 8. Best-corrected visual acuity improved in 13 of 18 eyes (72%) after treatment. Three cases developed recurrent retinal detachments that required repair with silicone oil.

Conclusions:

Most cases were HIV negative. Syphilitic uveitis can be the initial presentation of syphilis without classic systemic manifestation. Ophthalmologists play an important role in the diagnosis and treatment of syphilis.

Inpatient Adherence to Topical Glaucoma Medications before and after an Educational Intervention

PURPOSE

To assess the inpatient adherence rate and factors associated with adherence to topical glaucoma medications (TGMs) at a single academic institution throughout hospitalization before and after an educational intervention.

DESIGN

Nonrandomized, comparative, retrospective study.

PARTICIPANTS

Inpatients 18 years of age and older admitted to a single academic hospital from January 2014 through June 2019 with a diagnosis of glaucoma who also received TGMs.

METHODS

The medication administration record during admission was examined closely to determine if the TGMs were reconciled and administered correctly before and after an educational intervention with inpatient providers. A simple intervention reached various health care providers through an educational e-mail, communication in a weekly newsletter, and a morning report presentation. Adherence was defined as administration of more than 75% of recommended doses during the inpatient stay. Other collected variables included length of stay and primary diagnosis on admission.

MAIN OUTCOME MEASURES

Adherence rate to inpatient administration of TGMs.

RESULTS

One hundred eighty-four patients (n = 142 before intervention; n = 42 after intervention) were included. The preintervention group had a total of 275 TGMs, of which 207 (75.3%) were administered in accordance with the adherence definition of this study. After the intervention phase, 49 of 56 (87.5%) TGMs were administered with appropriate adherence (P = 0.047). Adherence was associated significantly with a known outpatient medication regimen (P = 0.006) and correct admission reconciliation (P < 0.001).

CONCLUSIONS

When glaucoma patients requiring topical treatment are admitted, approximately one quarter of patients seem to not receive their medications appropriately. In this study, a simple educational intervention was able to improve adherence. To prevent daily fluctuations in intraocular pressure for vulnerable glaucoma patients, inpatient adherence to appropriate medication administration should be stressed continuously. While in the care of health care providers, inpatients should be afforded at least the opportunity to maintain adequate adherence, just as is carried out for other medications related to other chronic medical conditions.

Frequency of Rhegmatogenous Retinal Detachment after Intravitreal Therapy in Neovascular Age-Related Macular Degeneration

PURPOSE

To identify characteristics of neovascular age-related macular degeneration (nAMD) patients undergoing pars plana vitrectomy (PPV) after rhegmatogenous retinal detachment (RRD), including changes to injection intervals.

DESIGN

Single-center retrospective, consecutive review.

PARTICIPANTS

All patients with RRD receiving anti-vascular endothelial growth factor treatment for nAMD from January 1, 2014, through October 30, 2018.

METHODS

Billing codes were used to identify RRD that occurred within 90 days of a previous intravitreal injection for nAMD.

MAIN OUTCOME MEASURES

Outcome measures included the quadrant of the retinal break(s), visual acuity at the time of RRD and final follow-up, and postoperative injection frequency.

RESULTS

An exact total of 203 000 intravitreal injections for nAMD were administered. Seventeen eyes from 17 patients demonstrated RRDs, giving a rate of 1 RRD per 11 941 intravitreal injections (0.0084%) within 90 days of intravitreal injection. Patients received a mean of 27.56 injections in the superotemporal quadrant before RRD. Of known retinal breaks, the superotemporal quadrant was involved most frequently (10 of 16 eyes [62.5%]). Six patients (35.3%) required a second surgery. Of patients requiring postoperative injections, the average interval increased from 7.18 weeks to 9.17 weeks after surgery. Eleven of 17 patients (64.7%) either increased their injection intervals or required no further injections, 3 maintained similar intervals, and 3 decreased intervals. The average number of injections in the 6 months before RRD (n = 84) and the 6 months after the first injection after PPV (n = 47) was 4.94 ± 1.89 and 2.76 ± 2.44, respectively (P = 0.009).

CONCLUSIONS

Based on these results, the 90-day rate of RRD in nAMD patients receiving intravitreal injections is low. Rhegmatogenous retinal detachments in these patients may be more difficult to repair. Although many physicians worry about injection frequency in vitrectomized eyes because of a presumed increased medication clearance, this study found that most patients received fewer injections after surgery.

Hemifacial Spasm in an Argus II Retinal Prosthesis Patient

PURPOSE

A 59-year-old man with retinitis pigmentosa, who received an Argus II retinal prosthesis in the left eye 3 years prior, presented with left-sided involuntary facial contractions that occurred only after turning on the Argus II device.

METHODS

A case report.

RESULTS

Given that this patient's reported and visualized lower eyelid twitching corresponds to the location of the external region of the implanted coil, we hypothesize that heat or wirelessly transmitted electrical signals from the external coil to the implanted coil may induce spasm of the facial nerve and thus play a role in hemifacial spasm onset.

CONCLUSIONS

To our knowledge, this is the first report of hemifacial spasm associated with Argus II use.

Late-Onset Retinal Findings and Complications in Untreated Retinopathy of Prematurity

PURPOSE

To investigate late retinal findings and complications of eyes with a history of retinopathy of prematurity (ROP) that did not meet treatment criteria and did not receive treatment during infancy.

DESIGN

Retrospective, nonconsecutive, noncomparative, multicenter case series.

PARTICIPANTS

Three hundred sixty-three eyes of 186 patients.

METHODS

Data were requested from multiple providers on premature patients with a history of ROP and no treatment during infancy who demonstrated late retinal findings or complications and included age, gender, gestational age and weight, zone and stage at infancy, visual acuity, current retina vascularization status, vitreous character, presence of peripheral retinal findings such as lattice retinal tears and detachments (RDs), retinoschisis, and fluorescein findings.

MAIN OUTCOME MEASURES

Rate of RDs and factors conferring a higher risk of RDs.

RESULTS

The average age was 34.5 years (range, 7-76 years), average gestational age was 26.6 weeks (range, 23-34 weeks), and average birth weight was 875 g (range, 425-1590 g). Findings included lattice in 196 eyes (54.0%), atrophic holes in 126 eyes (34.7%), retinal tears in 111 eyes (30.6%), RDs in 140 eyes (38.6 %), tractional retinoschisis in 44 eyes (11.9%), and visible vitreous condensation ridge-like interface in 112 eyes (30.5%). Fluorescein angiography (FA) was performed in 113 eyes, of which 59 eyes (52.2%) showed leakage and 16 eyes (14.2%) showed neovascularization. Incomplete vascularization posterior to zone 3 was common (71.6% of eyes). Retinal detachments were more likely in patients with a gestational age of 29 weeks or less (P < 0.05) and in eyes with furthest vascularization to posterior zone 2 eyes compared with zone 3 eyes (P = 0.009).

CONCLUSIONS

Eyes with ROP not meeting the treatment threshold during infancy showed various late retinal findings and complications, of which RDs were the most concerning. Complications were seen in all age groups, including patients born after the Early Treatment for Retinopathy of Prematurity Study. Contributing factors to RDs included atrophic holes within peripheral avascular retina, visible vitreous condensation ridge-like interface with residual traction, and premature vitreous syneresis. We recommend regular examinations and consideration of ultra-widefield FA examinations. Prospective studies are needed to explore the frequency of complications and benefit of prophylactic treatment and if eyes treated with anti-vascular endothelial growth factor therapy are at risk of similar findings and complications.

Management of Suture Penetration in Combined Vitrectomy and Scleral Buckle Surgery

Purpose:

To evaluate the surgical outcome of deep or full-thickness suture penetration during combined pars plana vitrectomy and scleral buckle (PPV/SB) surgery.

Methods:

Clinical data of patients who underwent PPV/SB for retinal detachment in our practice between June 2017 and April 2019 were reviewed. Cases with full-thickness scleral penetration were identified. Data including initial presentation, intraoperative complications, and management were collected. Long-term surgical outcome, complications, and recurrent detachment were determined.

Results:

Twenty-three cases with evidence of suture penetration were identified. In none of the cases the penetrated suture was visible in the subretinal space. The suture was replaced in cases with persistent leakage through the penetration site or when the surgical plan involved silicone oil insertion. Subretinal hemorrhage was noted during vitrectomy in 7 (30%) patients. The subretinal hemorrhage migrated to the macula in 2 (9%) cases and was drained through a posterior retinotomy. Retinal incarceration was noted in 4 (17%) cases and was released using a focal retinotomy in 2 (9%)cases to reattach the retina. Late complications included epiretinal membrane in 6 (26%) and recurrent detachment occurred in 2 (9%) patients. Final anatomical success was achieved in all patients.

Conclusions:

We propose new principles in the management of suture penetration during combined PPV/SB surgery. In the absence of a visible penetrated suture, suture replacement is required when there is profuse leakage through the penetration site or if silicone oil is used as tamponade. We recommend removal of submacular hemorrhage through a posterior retinotomy. The incarcerated retina can be flattened using release retinotomies.

Post-intravitreal injection endophthalmitis secondary to Turicella otitidis: a case report

Background

Endophthalmitis is a rare but potentially devastating complication of intravitreal injection. The causative organism plays an important role in prognosis following endophthalmitis. Here we present the first reported case of Turicella otitidis endophthalmitis, which is notable for a delayed presentation.

Case presentation

A 71 year old male who was receiving intravitreal aflibercept injections for neovascular age-related macular degeneration presented 4 weeks after his most recent intravitreal injection and was found to have endophthalmitis. Polymerase chain reaction (PCR) testing of aqueous fluid was positive for Turicella otitidis. The endophthalmitis responded well to treatment with intravitreal antibiotics.

Conclusions

Coryneform bacteria are a rare cause of endophthalmitis, and this is the first reported case of endophthalmitis caused by the corynebacterium species Turicella otitidis. As in this case, post-intravitreal injection endophthalmitis may have a bacterial etiology even with delayed presentation. The relatively indolent disease course and excellent response to intravitreal antibiotics is consistent with previous ophthalmic reports regarding other corynebacteria, as well as with otolaryngology and hematology oncology reports addressing Turicella otitidis specifically. This case supports the growing body of evidence for pathogenicity of Turicella otitidis and demonstrates the utility of PCR for diagnosis in small volume aqueous specimens.

Intrastromal bevacizumab in the management of corneal neovascularization: a retrospective review

PURPOSE

To evaluate the long-term safety and efficacy of intrastromal bevacizumab for treatment of deep corneal neovascularization in candidates for high-risk cornea grafting.

METHODS

A single-center retrospective study involving 14 eyes of 14 patients with chronic deep corneal neovascularization, treated with intrastromal bevacizumab by a single provider from 2011 to present. Intrastromal bevacizumab (0.05-0.1 mL of 2.5 mg/0.1 mL) was administered every 4-8 weeks. On average 1-3 intrastromal injections were performed prior to corneal grafting (penetrating keratoplasty or deep anterior lamellar keratoplasty).

RESULTS

64.2% patients had neurotrophic keratitis secondary to herpes zoster or simplex. Neovascularization was encroaching the visual axis in 50% and was paracentral in 42.8%. After intrastromal bevacizumab injection, 14.2% had complete regression of neovascularization, avoiding the need of future corneal transplant. Persistent neovascularization was noticed in 21.4%. Successful penetrating keratoplasty was performed in 57% of patients. Minimal adverse effects were noted; temporary epithelial defect was seen in two eyes and self-limited intrastromal hemorrhage in one. There was no evidence of recurrence of neovascularization or graft rejection in the transplant group (mean follow-up 3 years).

CONCLUSION

Intrastromal bevacizumab appears to be a safe and effective modality in the treatment of chronic corneal neovascularization, producing durable regression of corneal neovascularization and allowing for durable success of subsequent corneal transplants in high-risk patients.

A child with unilateral disk elevation

A healthy 7-year-old girl underwent a routine eye examination and was referred for unilateral, left optic nerve swelling. Best-corrected visual acuity in the affected eye was 20/20 with full Ishihara color plates and no relative afferent pupillary defect. Initial extensive workup was normal for any cause of unilateral disk swelling. When the patient returned a few years later with decreased vision, a thickened, gray-white preretinal tissue with surrounding retinal contraction and a surrounding charcoal gray lesion had developed in her optic nerve. Spectral-domain optical coherence tomography over the optic nerve demonstrated distortion of the inner retinal architecture, a dense epiretinal membrane, and high internal reflectivity. Clinical examination and imaging revealed a diagnosis of combined hamartoma of the retina and retinal pigment epithelium.

Isolated cilioretinal artery occlusion secondary to perinuclear antineutrophil cytoplasmic antibody vasculitis

INTRODUCTION

Antineutrophil cytoplasm antibody-associated vasculitides encompass a diverse spectrum of autoimmune diseases characterized by necrotizing small vessel vasculitis. Ocular manifestations may be the presenting findings of antineutrophil cytoplasm antibody-associated vasculitides.

METHODS

Single, retrospective case study.

RESULTS

We report the rare case of a 55-year-old woman with a cilioretinal artery occlusion as the presenting feature of perinuclear antineutrophil cytoplasm antibody-associated microscopic polyangiitis.

CONCLUSIONS

Although rare, antineutrophil cytoplasm antibody-related vasculitis should be considered in any retinal vascular occlusion, particularly in the setting of patients with new vague headaches and a paucity of vasculopathic risk factors.