Mechanism and outcomes of recreational and sports-related open globe injuries

OBJECTIVES

To describe the mechanisms and visual outcomes of recreational and sports-related open globe injuries (OGIs).

METHODS

A retrospective case series of eyes experiencing OGI secondary to recreational and sports-related activities at Memorial Hermann Hospital - Texas Medical Center (MHH-TMC) from January 1st, 2010 through March 31st, 2015 was conducted. Exclusionary criteria included no documented ophthalmologic examination upon presentation and repairs performed by services other than ophthalmology. A two-tailed t-test and Fisher's exact test were utilized to assess for statistical significance (p < 0.05).

RESULTS

A total of 20 eyes from 20 patients experiencing OGIs secondary to recreational and sports-related activities were included. Thirteen eyes (65 %) presented with OGIs from penetrating objects while seven eyes (35 %) had injuries from blunt injuries. Males comprised most of the total study group (17 of 20 patients), and zone 3 injuries were the most common location of OGI. While eyes with OGIs from blunt trauma underwent evisceration/enucleation procedures more frequently than OGIs from penetrating mechanisms (71% vs 23 %) (p = 0.10), the final visual outcomes were similarly poor between groups. Only three eyes in this series experienced an improvement from baseline VA; all three eyes had lacked initial findings consistent with severe injury.

CONCLUSIONS

Recreational and sports related OGIs most commonly occur in zone 3 and in young males, regardless of injury type. OGIs due to both penetrating and blunt trauma mechanisms implicate poor functional outcomes, but the absence of certain presenting injury features may indicate possibility of eventual visual recovery.

The Use of Large Language Models to Generate Education Materials about Uveitis

OBJECTIVE

To assess large language models in generating readable uveitis information and in improving the readability of online health information.

DESIGN

Evaluation of technology.

SUBJECTS

Not applicable.

METHODS

ChatGPT and Bard were asked the following prompts: (prompt A) "considering that the average American reads at a 6th grade level, using the Flesch-Kincaid Grade Level (FKGL) formula, can you write patient-targeted health information on uveitis of around 6th grade level?" and (prompt B) "can you write patient-targeted health information on uveitis that is easy to understand by an average American?" Additionally, ChatGPT and Bard were asked the following prompt from the first-page results of Google when the term "uveitis" was searched: "Considering that the average American reads at a 6th grade level, using the FKGL formula, can you rewrite the following text to 6th grade level: [insert text]." The readability of each response was analyzed and compared using several metrics described below.

MAIN OUTCOME MEASURES

The FKGL is a highly validated readability assessment tool that assigns a grade level to a given text, the total number of words, sentences, syllables, and complex words. Complex words were defined as those with > 2 syllables.

RESULTS

ChatGPT and Bard generated responses with lower FKGL scores (i.e., easier to understand) in response to prompt A compared with prompt B. This was only significant for ChatGPT (P < 0.0001). The mean FKGL of responses to ChatGPT (6.3 ± 1.2) was significantly lower (P < 0.0001) than Bard 10.5 ± 0.8. ChatGPT responses also contained less complex words than Bard (P < 0.0001). Online health information on uveitis had a mean grade level of 11.0 ± 1.4. ChatGPT lowered the FKGL to 8.0 ± 1.0 (P < 0.0001) when asked to rewrite the content. Bard was not able to do so (mean FKGL of 11.1 ± 1.6).

CONCLUSIONS

ChatGPT can aid clinicians in producing easier-to-understand health information on uveitis for patients compared with already-existing content. It can also help with reducing the difficulty of the language used for uveitis health information targeted for patients.

FINANCIAL DISCLOSURE(S)

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

Ophthalmic manifestations of tuberculosis

PURPOSE OF REVIEW

To evaluate the epidemiology, microbiology, and pathology of Mycobacterium Tuberculosis (MTB). Utilizing these basic science concepts, the reader will discover how MTB can cause disease in any part of ophthalmic system. This article will aid clinicians in establishing the difficult diagnosis and management strategies for ophthalmic tuberculosis (OTB).

RECENT FINDINGS

Recently, expert panels have reached a consensus on naming conventions and treatment strategies for the variety of ocular tuberculosis (TB). This consensus helps individual clinicians decide when to recommend full anti-TB treatment.

SUMMARY

Globally, TB is nearly ubiquitous in the human population. It is most recognized for its pulmonary disease, but pathology of nearly every structure of the ophthalmic system has been identified. This heterogeneity makes establishing a diagnosis difficult, but recent improvements in expert panel naming consensus and nucleic acid amplification tests are improving diagnostic abilities. Clinicians are now feeling more confident with prescribing anti-TB regimens, but ongoing questions regarding the use of oral steroids and risk of medication-induced ocular toxicity remain.

Postoperative Complications of True Dropless Cataract Surgery versus Standard Topical Drops

Purpose  Compare postoperative outcomes in cataract surgery between eyes with standard drop regimen versus dropless protocol by residents. Design  Retrospective cohort study between April 1, 2018 and March 31, 2020. Methods  The study was performed at Lyndon B. Johnson General Hospital in Houston, Harris County, Texas. A total of 547 eyes (234 dropless vs. 313 standard) with phacoemulsification cataract surgery and minimum of 1-month follow-up with best-corrected visual acuity (BCVA) were included. Dropless received 40 mg sub-Tenon's triamcinolone and intracameral moxifloxacin. Patients were followed at postoperative day 1 (POD1), week 1 (POW1), and month 1 (POM1). Postoperative rate of BCVA better than 20/40 (Good vision) and rate of complications were compared between groups. Results  Good vision on POM1 in dropless (77.8%) was noninferior to standard (75.1%, p  = 0.80). Complication rate in dropless (28.6%) was noninferior to standard (24.0%, p  = 0.13). Intraocular pressure (IOP) elevation on POD1 ( p  = 0.041) and anterior chamber (AC) cells on POW1 and POM1 ( p  < 0.001) were more frequent in dropless. Mean spherical equivalent at POM1 was better in dropless (-0.37 D [±0.81 D]) compared with standard (-0.61D [±0.77 D], p  = 0.001). Early posterior capsular opacification (early PCO) was more frequent in dropless ( p  = 0.042). Conclusions  Postoperative rate of BCVA better than 20/40 and rate of postoperative complications were noninferior, although dropless had higher rates of AC inflammation, IOP elevation, and early PCO.

Non-traumatic open globe injuries: presenting characteristics and visual outcomes

PURPOSE

To describe clinical characteristics and visual outcomes of non-traumatic open globe injuries.

SETTING

A level 1 trauma centre in a large urban medical centre.

DESIGN

Retrospective study.

METHODS

Charts of non-traumatic open globe patients admitted to MHH-TMC from 1/2010 to 3/2015 were reviewed for demographics, cause, clinical characteristics, visual acuity (VA) and enucleation.

RESULTS

Thirty eyes were included: 15 (50%) were males with a mean age of 47 (±28) years. All presented with zone 1 injury. Twenty-five (83%) had a perforated corneal ulcer. Presenting VA was count fingers (n = 3, 10%) to NLP (n = 6, 20%). Twenty-four (80%) involved infection, 5 (17%) congenital, 3 (10%) chemical burn and 2 (7%) neurotrophic. Conjunctival injection (n = 22, 77%), corneal opacification (n = 20, 71%) and relative afferent pupillary defect (n = 9, 44%) were common. After treatment, 23 (88%) were worse than 6/60 (20/200), 9 (35%) were NLP and 8 (27%) required enucleation.

CONCLUSIONS

Often non-traumatic open globe injuries are zone 1 and due to perforated infectious ulcers. Compared to previously reported traumatic injuries, these have higher rates of enucleation (27% vs 8%) and poorer final VA (88% vs 68% worse than 6/60 20/200).

Case series: Traumatic ocular lacerations secondary to pressure washers

Purpose

Numerous causes of ocular lacerations, including, open globe injuries have been extensively reported but to our knowledge this is first time that pressure washers have been reported to be the culprit. Thus, in this case series we describe the uniqueness of ocular findings secondary to high-power pressure washer injuries that are a result of their mechanistic function.

Observations

Here we report a case series of 3 patients who presented in an emergency department with pain and decreased visual acuity following usage of high-pressure washer machines. All three patients presented with features of both blunt and sharp mechanisms of ocular injury. Most lacerations caused injury that encompassed more than one zone. Two of the patients experienced an open globe injury, and all patients had poor final visual outcomes. Extraocular involvement included fractures and lid lacerations. All patients were managed surgically with repair of the ocular defects. Visual outcome in the first patient was hand motion, while the second patient received a prosthesis following enucleation due to lack of recovery after four months. Lastly, we were unable able to obtain visual outcome for the third patient due to lack of follow up.

Conclusion

Ocular injuries due to pressure washers have not been reported in literature, however, this case series serves to elucidate that pressure washers can cause ocular injuries with both blunt and laceration mechanical effects. Moreover, special care should be taken in preventing and managing these injuries due to their high ocular morbidity.

Treatment Outcomes in Birdshot Chorioretinitis: Corticosteroid Sparing, Corticosteroid Discontinuation, Remission, and Relapse

PURPOSE

To describe treatment-related outcomes among patients with birdshot chorioretinitis (BSCR).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients diagnosed with BSCR at 2 tertiary care academic medical centers.

METHODS

Clinical and treatment-related data were collected for all patients with BSCR diagnosed between 2003 and 2017 at the 2 centers and for each eye at each clinical visit.

MAIN OUTCOME MEASURES

Four outcomes were considered: (1) corticosteroid-sparing success, defined as inactive disease and prednisone dose of ≤7.5 mg/day; (2) corticosteroid-discontinuation success, defined as inactive disease and discontinuation of prednisone; (3) sustained drug-free remission, defined as inactive disease off all medications for ≥3 months; and (4) relapse of BSCR after remission.

RESULTS

A total of 107 patients with BSCR were identified, of whom 94 had follow-up data. Corticosteroid-sparing success was achieved in 95.4% of the oral corticosteroid-treated patients at a rate of 0.60 successes per person-year (PY) (95% CI: 0.50/PY, 0.70/PY). The median time to corticosteroid-sparing success was 12 months. Corticosteroids were discontinued successfully in 76.5% of oral corticosteroid-treated patients (rate = 0.28/PY; 95% CI: 0.21/PY, 0.35/PY). The median time to successful corticosteroid discontinuation was 2.0 years. A sustained drug-free remission was achieved in 24 patients (rate = 0.06/PY; 95% CI: 0.04/PY, 0.09/PY), with approximately 25% of patients achieving remission by 4 years of follow-up. Relapse of inflammation in patients after achieving a sustained, drug-free remission occurred at a rate of 0.24/PY (95% CI: 0.14/PY, 0.37/PY).

CONCLUSIONS

Successful corticosteroid sparing and discontinuation was achieved in the majority of patients with BSCR. Remission occurred less often, but data were limited by the time needed to induce a remission (4 years) and the amount of follow-up (median, 4.6 years). The relapse rate after a remission was 0.24/PY.

Current Landscape of Uveitis Specialists in the United States

Purpose This study characterizes the current landscape of uveitis specialists and their practice settings in the United States.

Methods An anonymous Internet-based survey with questions pertaining to training history and practice characteristics was distributed via REDCap to the American Uveitis Society and Young Uveitis Specialists listservs.

Results Forty-eight uveitis specialists in the United States responded to the survey out of 174 uveitis specialists that identify as practicing in the United States. Twenty-five of 48 respondents (52%) completed an additional fellowship. These additional fellowships ranged from surgical retina (12/25, 48%), cornea (8/25, 32%), and medical retina (4/25, 16%). Two-thirds of uveitis specialists managed their own immunosuppression, while one-third comanaged immunosuppression with rheumatologists. Thirty-three of 48 (69%) maintained a surgical practice.

Conclusion This is the first survey of uveitis specialists across the United States to provide understanding into training and practice characteristics. These data will provide insight into career planning, practice building, and assist in resource allocation.

Alexandrite laser induced uveitis & pigment dispersion: A case report and review of the literature

Purpose

To describe a complication of an upper eyelid alexandrite laser procedure.

Observations

A 55-year-old woman presented with left eye blurred vision and photophobia after a left upper eyelid procedure with an alexandrite laser. She had elevated intraocular pressure (IOP), anterior chamber cell and pigment, posterior synechiae, and retroillumination defects in the left eye. She was treated with topical prednisolone and brimonidine. Six months later, although her anterior chamber had cleared and IOP had normalized, the patient reported decreased vision-related quality of life from persistent photophobia.

Conclusions and Importance

Alexandrite lasers are commonly used for hair removal and skin depigmentation. When used periocularly without proper eye protection, they have the potential to create irreversible ocular complications. This case demonstrates the importance of proper eye protection with periocular laser procedures.

Cost comparison of commonly used postoperative topical ophthalmic antibiotics

PURPOSE

To provide information on the actual fill level and cost of currently available antibiotic drops used perioperatively.

DESIGN

Prospective laboratory investigation.

SETTING

Robert Cizik Eye Clinic, Houston, Texas USA.

METHODS

The following 9 medications were tested: moxifloxacin, gatifloxacin (branded and generic), besifloxacin, levofloxacin, ciprofloxacin, ofloxacin, trimethoprim/polymyxin B, tobramycin, and gentamicin. Actual bottle-fill volume and number of drops per bottle were measured using 10 bottles of each formulation. The percentage of the bottle used and the perioperative cost (using average wholesale price) were calculated for 3 times a day and 4 times a day dosing for 7-day, 10-day, and 14-day courses. Formulations were compared using 1-way analysis of variance with Tukey multiple comparisons.

RESULTS

For medications with sticker volumes of at least 5 mL, all but 2 medications (ofloxacin, 4 times a day for 14 days; gentamicin, 4 times a day for 14 days) covered 2 perioperative courses. Besifloxacin had a fill volume less than the sticker volume. The most cost-effective perioperative antibiotic prophylaxis was trimethoprim-polymyxin B (4 times a day: $12.87 for 7-day, 10-day, and 14-day courses, and $46.88 for 4-day course; 3 times a day: $12.87 for 7-day, 10-day, and 14-day courses).

CONCLUSIONS

Most antibiotics had an actual fill volume greater than sticker volume, which is a sufficient drug regimen for 2 perioperative courses. The costs of common postoperative topical antibiotic regimens vary widely depending on the drug and dosing regimen. Cost considerations for perioperative antibiotics will be increasingly important because the number of cataract surgeries is expected to increase with the growing and aging population.

Burkitt lymphoma masquerading as Tolosa-Hunt syndrome in an HIV-seropositive patient

PURPOSE

To describe a rare case of Burkitt lymphoma metastatic to the cavernous sinus that was initially diagnosed as Tolosa-Hunt syndrome.

CASE DESCRIPTION

A 31-year-old confirmed and treatment-compliant HIV-positive Hispanic male acutely developed diplopia, ptosis, numbness in the V1 distribution, and complete external ophthalmoplegia in the right eye over 1 week. Imaging showed a mass-like lesion within the right cavernous sinus without other intracranial abnormalities. He was started on broad-spectrum antibiotics and antifungals without improvement. Inflammatory and infectious workup was negative. A presumed diagnosis of Tolosa-Hunt syndrome was made based on clinical and radiographic findings, as well as the absence of another etiology to explain the patient's presentation. He was then started on high-dose oral steroids with improvement of orbital pain only. Shortly after being discharged on steroids, the patient returned to the hospital with severe abdominal pain. Computed tomography of the abdomen showed perforated ileitis with aneurysmal dilation of the ileum and marked wall thickening concerning for a mass lesion. Positron emission tomography-computed tomography showed an uptake in the terminal ileum and right cavernous sinus consistent with metastatic Burkitt lymphoma, matching with pathology. After several cycles of chemotherapy, symptoms improved, and he regained full ocular motility in the affected eye. However, the patient ultimately died due to peritonitis and pyelonephritis.

CONCLUSION

Burkitt lymphoma metastatic to the cavernous sinus was diagnosed after an initial diagnosis of Tolosa-Hunt syndrome. Tolosa-Hunt syndrome is a diagnosis of exclusion and should only be made after ruling out other pathologies.

Repositioning a posteriorly dislocated silicone plate-haptic toric intraocular lens

We describe a technique for repositioning an encapsulated, posteriorly dislocated silicone plate-haptic toric intraocular lens (IOL) while preventing further dislocation into the vitreous cavity. Sutures of 10-0 polypropylene were used to ensure safe retrieval of the dislocated IOL. An anterior vitrectomy was then performed to remove the contracted capsular bag around the IOL. The IOL fixation hole was temporarily externalized to allow quick and secure IOL fixation, eliminating the risk for losing the slippery silicone IOL into the vitreous cavity. Using this technique, the IOL was successfully placed in the proper position and resulted in good vision for the patient while avoiding the trauma of lens exchange.

Paraneoplastic frosted branch angiitis as first sign of relapsed Hodgkin lymphoma

Frosted branch angiitis (FBA) is a rare form of retinal vasculitis with typical perivascular edema taking the shape of frost on a tree branch. It was reported only twice as the initial presentation of Hodgkin lymphoma (HL). Here, we present the first case of paraneoplastic FBA as the initial sign of HL relapse in an elderly female.

Idiopathic Central Nervous System Inflammatory Disease in the Setting of HLA-B27 Uveitis

Purpose: The purpose of the article is to describe a novel case of idiopathic central nervous system inflammatory disease with bilateral human leukocyte antigen (HLA)-B27-positive anterior uveitis. Methods/Results: A 15-year-old African American boy with bilateral HLA-B27-positive anterior uveitis controlled with topical and oral steroids for 8 months acutely developed headaches, left eyelid ptosis, and binocular diplopia. Imaging showed lesions in the right midbrain, superior colliculus, cerebellar peduncles, and cerebellar vermis and leptomeningeal enhancement along the vermian foliae. Cerebral spinal fluid tests showed mild lymphohistiocytic pleocytosis with negative cytology; inflammatory and infectious workup were negative. He received intravenous methylprednisolone without initial symptomatic improvement; repeat magnetic resonance imaging (MRI) showed reduced lesion burden. Oral steroids were continued; his symptoms resolved in 1 month. Repeat MRI 2 months after presentation showed almost complete lesion resolution. Conclusions: Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) was diagnosed. HLA-B27 positivity may represent a novel association with CLIPPERS.

Characterizing Anterior Segment OCT Angle Landmarks of the Trabecular Meshwork Complex

PURPOSE

To identify the presence or absence of 3 identifiable landmarks: trabecular meshwork (TM), Schlemm's canal (SC), and a novel landmark termed the band of extracanalicular limbal lamina (BELL), which is a landmark adjacent to SC visible on anterior segment (AS) OCT. These landmarks also were analyzed pathologically to identify all 3 landmarks.

DESIGN

Retrospective review.

PARTICIPANTS

One eye per participant from prior institutional review board-approved studies in which AS OCT imaging was performed.

METHODS

Horizontal images from 2-dimensional angle analysis scans using a CASIA SS-1000 (Tomey, Nagoya, Japan) AS OCT were evaluated by masked readers. Logistic regression was used to analyze the potential factors of age, gender, race, intraocular pressure, gonioscopy grade, angle location, and history or presence of surgery on the visibility of these structures. Pathologic correlation on 5 previously enucleated eyes also was performed.

MAIN OUTCOME MEASURES

Presence or absence of angle landmarks-TM, SC, and BELL-using Anterior Chamber Analysis and Interpretation software (ACAI, Houston, TX).

RESULTS

Three hundred three angles of 153 horizontal images were included in this study. The mean age was 51.5±16.0 years, with 98 women (64%) and 100 white persons (66%). The outer border of the BELL was observed in 288 angles (95%), TM was found in 220 angles (73%), and SC was seen in 120 angles (40%). The outer border of the BELL was more visible in white persons (P = 0.02) than Asians and in eyes with a Spaeth gonioscopy grade of E than those with a grade of A (P = 0.02). Both TM (P = 0.001) and SC (P = 0.001) were more visible in temporal angles (81% for TM, 49% for SC) than in nasal angles (64% for TM, 30% for SC). Additionally, SC was more visible in open angles (43%) than in narrow angles (27%; P = 0.02). These 3 structures were verified in a pathologic study.

CONCLUSIONS

We identified a novel AS OCT landmark adjacent to SC. This structure also was identified on pathologic samples from enucleated eyes. Further study is needed to determine the pathophysiologic relevance of these findings.

Orbital Inflammatory Syndrome and Anterior Uveitis: A Case Series

PURPOSE

To describe four cases of orbital inflammatory syndrome (OIS) with associated anterior uveitis that have presented within 2 years to our practice.

METHODS

Charts of patients diagnosed with OIS from June 2013 to May 2015 were reviewed.

RESULTS

Four patients, three children and one adult, presented with orbital swelling, pain, and varying degrees of vision loss. Treatment with intravenous methylprednisolone resulted in significant symptomatic improvement in all cases initially; when symptoms recurred, the patients had evidence of anterior uveitis. With continued systemic therapy and the addition of topical prednisolone, the patients all achieved control of their uveitis and OIS and are well controlled with regular outpatient follow-up.

CONCLUSIONS

Reports of OIS-associated with uveitis are relatively rare. The presentation of three pediatric patients and one adult patient to the same practice with OIS and secondary uveitis within a 2-year period may indicate that the association is underreported.

Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult Open Globe Injuries by Neuroradiology and Ophthalmology

OBJECTIVE

The objective was to evaluate the sensitivity and specificity of computed tomography (CT) diagnosis of open globes, determine which imaging factors are most predictive of open globe injuries, and evaluate the agreement between neuroradiologist and ophthalmologist readers for diagnosis of open and closed globes.

METHODS

This study was a retrospective cohort study. Patients who presented to Memorial Hermann-Texas Medical Center with suspicion for open globes were reviewed. One neuroradiologist and two ophthalmologists masked to clinical information reviewed CT images for signs concerning for open globe including change in globe contour, anterior chamber deformation, intraocular air, vitreous hemorrhage, subretinal fluid indicating retinal or choroidal detachment, dislocated or absent lens, intraocular foreign body, and orbital fracture. Using the clinically or surgically confirmed globe status as the true globe status, sensitivity, specificity, and agreement (kappa) were calculated and used to investigate which imaging factors are most predictive of open globe injuries.

RESULTS

A total of 114 patients were included: 35 patients with open globes and 79 patients with closed globes. Specificity was greater than 97% for each reader, and sensitivity ranged from 51% to 77% among readers. The imaging characteristics most consistently used to predict an open globe injury were change in globe contour and vitreous hemorrhage (sensitivity = 43% to 57%, specificity > 98%). The agreement of impression of open globe between the neuroradiologist and ophthalmologists was good and excellent between ophthalmologists.

CONCLUSIONS

Computed tomography imaging is not absolute, and the sensitivity is still inadequate to be fully relied upon. The CT imaging findings most predictive of an open globe injury were change in globe contour and vitreous hemorrhage. Clinical examination or surgical exploration remains the most important component in evaluating for a suspected open globe, with CT imaging as an adjunct.