Evolution of Autoimmune Retinopathy in Stiff Person Syndrome: A Case Report

PURPOSE

To report a case of autoimmune retinopathy (AIR) as the presenting feature of Stiff Person Syndrome (SPS) and assess its evolution.

OBSERVATIONS

A 35-year-old man presented with progressive, chronic, vision loss. On initial examination, visual acuity measured 20/20 OD and 20/50 OS. Humphrey Visual Field testing (HVF) demonstrated decreased foveal threshold OU. Mild subfoveal ellipsoid zone loss was noted on Optical Coherence Tomography (OCT). Five years later the patient presented with painful lower extremity muscle spasms and stiffness and complained of increasing vision loss with difficulty distinguishing colors. OCT showed marked progression of ellipsoid zone loss. Scotoma were demonstrated on HVF and electroretinography demonstrated reduced responses consistent with bilateral severe maculopathy. Serum testing showed autoantibodies to the glutamic acid decarboxylase 65-kilodalton isoform (GAD65) at a high titer and a diagnosis of AIR in the setting of SPS was made. A systemic workup for malignancy was negative. The patient was treated with IVIG and transitioned to rituximab with improvement in systemic symptoms.

CONCLUSIONS

and Importance: Unlike previous cases of AIR in the setting of SPS, vision symptoms and OCT changes presented years before the onset of muscle spasms. Etiologies such as SPS should be on the differential of unexplained retinopathy, even in the absence of systemic symptoms, especially when paraneoplastic etiologies are ruled out.

Gradeability and Reproducibility of Geographic Atrophy Measurement in GATHER-1, a Phase II/III Randomized Interventional Trial

Objective

To validate GATHER-1 inclusion criteria and the study's primary anatomic end point by assessing the reproducibility of geographic atrophy (GA) measurements and factors that affect reproducibility.

Design

Post hoc analysis of phase II/III clinical trial.

Subjects

All 286 participants included in the GATHER-1 study.

Methods

For each subject, blue-light fundus autofluorescence (FAF), color fundus photographs, fluorescein angiograms, and OCT scans were obtained on the study eye and fellow eye. Geographic atrophy area and other lesion characteristics were independently graded by 2 experienced primary readers. If the 2 readers differed on gradeability, GA area (> 10%) or other lesion characteristics, the image was graded by an arbitrator whose measurement or characterization was the final grade.

Main Outcome Measures

The main outcome measures were gradeability and reproducibility of FAF imaging data. Imaging data included lesion area, confluence of GA with peripapillary atrophy (PPA), whether GA involved the foveal centerpoint, and type of hyperautofluorescence pattern.

Results

A total of 2004 images (1002 visits, 286 participants) were analyzed. Gradeability (90.5%) and interreader gradeability concordance (90.2%) were high across all visits. Study eye images were more gradable compared with fellow-eye images. A greater proportion of smaller lesions required arbitration, but interreader reproducibility was consistently high for all images. There was no difference in gradeability, gradeability concordance, or lesion-area concordance for images with PPA-confluent GA compared with those with nonconfluent PPA. Foveal centerpoint-involving lesions had lower gradeability and lesion-area concordance. Images with diffuse patterns of hyperautofluorescence had better gradeability and gradeability concordance than those with nondiffuse patterns but had no difference in lesion-area or lesion-area concordance.

Conclusions

There is high gradeability and excellent reproducibility measures across all images. These data support the validity of conclusions from GATHER-1 and the chosen inclusion criteria and end point.

Financial Disclosures

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

Peripapillary Optical Coherence Tomography Angiography in Alzheimer's Disease, Mild Cognitive Impairment, and Normal Cognition

OBJECTIVE

This study aimed to identify peripapillary microvascular changes in Alzheimer's disease (AD) and mild cognitive impairment (MCI).

PATIENTS AND METHODS

In this prospective study, 66 eyes of 36 subjects with AD, 119 eyes of 63 with MCI, and 513 eyes of 265 controls with normal cognition were enrolled. Peripapillary capillary perfusion density (CPD), capillary flux index (CFI), and retinal nerve fiber layer (RNFL) thickness were determined.

RESULTS

Average CPD differed significantly between all three groups (P = 0.001), being significantly greater in AD vs controls (0.446 ± 0.015 vs 0.439 ± 0.017, P = 0.001) and MCI vs controls (0.443 ± 0.020 vs 0.439 ± 0.017, P = 0.007) but not AD vs MCI (P = 0.69). CFI and average RNFL thickness did not significantly differ among groups (all P > 0.05).

CONCLUSION

Peripapillary CPD is increased in eyes with AD or MCI compared to controls despite similar RNFL thickness. [Ophthalmic Surg Lasers Imaging Retina 2024;55:78-84.].

Characterizing differences in retinal and choroidal microvasculature and structure in individuals with Huntington's Disease compared to healthy controls: A cross-sectional prospective study

OBJECTIVE

To characterize retinal and choroidal microvascular and structural changes in patients who are gene positive for mutant huntingtin protein (mHtt) with symptoms of Huntington's Disease (HD).

METHODS

This study is a cross-sectional comparison of patients who are gene positive for mHtt and exhibit symptoms of HD, either motor manifest or prodromal (HD group), and cognitively normal individuals without a family history of HD (control group). HD patients were diagnosed by Duke movement disorder neurologists based on the Unified Huntington's Disease Rating Scale (UHDRS). Fovea and optic nerve centered OCT and OCTA images were captured using Zeiss Cirrus HD-5000 with AngioPlex. Outcome metrics included central subfield thickness (CST), peripapillary retinal nerve fiber layer (pRNFL) thickness, ganglion cell-inner plexiform layer (GCIPL) thickness, and choroidal vascularity index (CVI) on OCT, and foveal avascular zone (FAZ) area, vessel density (VD), perfusion density (PD), capillary perfusion density (CPD), and capillary flux index (CFI) on OCTA. Generalized estimating equation (GEE) models were used to account for inter-eye correlation.

RESULTS

Forty-four eyes of 23 patients in the HD group and 77 eyes of 39 patients in the control group were analyzed. Average GCIPL thickness and FAZ area were decreased in the HD group compared to controls (p = 0.001, p < 0.001). No other imaging metrics were significantly different between groups.

CONCLUSIONS

Patients in the HD group had decreased GCIPL thickness and smaller FAZ area, highlighting the potential use of retinal biomarkers in detecting neurodegenerative changes in HD.

Ultra-Widefield Imaging of the Retinal Macrovasculature in Parkinson Disease Versus Controls With Normal Cognition Using Alpha-Shapes Analysis

Purpose

To investigate retinal vascular characteristics using ultra-widefield (UWF) scanning laser ophthalmoscopy in Parkinson disease (PD).

Methods

Individuals with an expert-confirmed clinical diagnosis of PD and controls with normal cognition without PD underwent Optos California UWF imaging. Patients with diabetes, uncontrolled hypertension, glaucoma, dementia, other movement disorders, or known retinal or optic nerve pathology were excluded. Images were analyzed using Vasculature Assessment and Measurement Platform for Images of the Retina (VAMPIRE-UWF) software, which describes retinal vessel width gradient and tortuosity, provides vascular network fractal dimensions, and conducts alpha-shape analysis to further characterize vascular morphology (complexity, Opαmin; spread, OpA).

Results

In the PD cohort, 53 eyes of 38 subjects were assessed; in the control cohort, 51 eyes of 33 subjects were assessed. Eyes with PD had more tortuous retinal arteries in the superotemporal quadrant (P = 0.043). In eyes with PD, alpha-shape analysis revealed decreased OpA, indicating less retinal vasculature spread compared to controls (P = 0.032). Opαmin was decreased in PD (P = 0.044), suggesting increased vascular network complexity. No differences were observed in fractal dimension in any region of interest.

Conclusions

This pilot study suggests that retinal vasculature assessment on UWF images using alpha-shape analysis reveals differences in retinal vascular network spread and complexity in PD and may be a more sensitive metric compared to fractal dimension.

Translational Relevance

Retinal vasculature assessment using these novel methods may be useful in understanding ocular manifestations of PD and the development of retinal biomarkers.

Imaging Features of Retinal Vasculitis and/or Retinal Vascular Occlusion after Brolucizumab Treatment in the Postmarketing Setting

Purpose

The aim of this analysis was to characterize the spectrum of inflammatory changes arising from brolucizumab use in routine clinical practice.

Design

Retrospective analysis of fluorescein angiography (FA), fundus photography (FP) and OCT images taken at the time of adverse event.

Subjects

Brolucizumab-treated patients with neovascular age-related macular degeneration with retinal vasculitis (RV) and/or retinal vascular occlusion (RO) reported to Novartis Patient Safety between February 2020 and January 2021.

Methods

Ocular images were reviewed by an external reading center using predefined grading lists for FA, FP, and OCT.

Main Outcome Measures

Classification of images, the most common imaging features of RV and/or RO by each imaging modality, and the anatomical location of the adverse event in relation to the macula.

Results

Gradable images (N = 475; 222 eyes; 198 patients) were classified as RV only (n = 72); RO only (n = 9), RV + RO (n = 63); posterior segment intraocular inflammation (n = 31); or none by imaging (n = 47). Of the 144 eyes with RV and/or RO, the most common imaging features were vascular leakage on FA, perivascular sheathing on FP, and hyperreflective dots in the vitreous humor on OCT. Retinal vascular occlusion was mainly branched and arterial, affecting multiple vessels.

Conclusions

Although no distinct inflammatory phenotype pathognomonic to brolucizumab-related inflammation was identified, this study increases our understanding of the spectrum of posterior segment inflammatory changes that may occur in brolucizumab-treated neovascular age-related macular degeneration patients, highlighting the potential value of widefield retinal imaging and angiography to detect these inflammatory adverse events.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Differences in Retinal and Choroidal Microvasculature and Structure in Dementia With Lewy Bodies Compared With Normal Cognition

Purpose: To evaluate the retinal and choroidal microvasculature and structure in individuals with dementia with Lewy bodies (DLB) compared with controls with normal cognition using optical coherence tomography (OCT) and OCT angiography (OCTA). Methods: An institutional review board-approved cross-sectional comparison of patients with DLB and cognitively normal controls was performed. The Cirrus HD-OCT 5000 with AngioPlex (Carl Zeiss Meditec) was used to obtain OCT and OCTA images. Results: Thirty-four eyes of 18 patients with DLB and 85 eyes of 48 cognitively normal patients were analyzed. The average capillary perfusion density (CPD) was higher in the DLB group than in the control group (P = .005). The average capillary flux index (CFI) and ganglion cell inner-plexiform layer (GC-IPL) thickness were lower in the DLB group than in the control group (P = .016 and P = .040, respectively). Conclusions: Patients with DLB had an increased peripapillary CPD, decreased peripapillary CFI, and attenuated GC-IPL thickness compared with those with normal cognition.

Wide Field Optical Coherence Tomography and Optical Coherence Tomography Angiography in Uveitis

BACKGROUND

We review the current literature on the use of wide-field optical coherence tomography (OCT) and wide-field optical coherence tomography angiography (OCTA) in different uveitic phenotypes as well as various sequelae of uveitis and discuss the limitations of this evolving technology.

MAIN BODY

Current consensus guidelines on nomenclature in wide-field OCT and OCTA are described. The specific utility of wide-field OCT and OCTA in assessment of the retina and choroid using different en-face and cross-sectional slabs in various inflammatory diseases is reviewed. Furthermore, we discuss widefield OCT and OCTA in assessment of retinal ischemia and its limitations in assessing retinal vascular leakage.

CONCLUSION

Wide-field OCT and OCTA deliver more sensitive measures of inflammation. With continued advancement in both hardware technology and software processing, these modalities will allow for more accurate assessment of uveitis, better understanding of disease mechanisms, and precise monitoring of treatment response.

A Convolutional Neural Network Using Multimodal Retinal Imaging for Differentiation of Mild Cognitive Impairment from Normal Cognition

Purpose

To develop a machine learning tool capable of differentiating eyes of subjects with normal cognition from those with mild cognitive impairment (MCI) using OCT and OCT angiography (OCTA).

Design

Evaluation of a diagnostic technology.

Participants

Subjects with normal cognition were compared to subjects with MCI.

Methods

A multimodal convolutional neural network (CNN) was built to predict likelihood of MCI from ganglion cell-inner plexiform layer (GC-IPL) thickness maps, OCTA images, and quantitative data including patient characteristics.

Main Outcome Measures

Area under the receiver operating characteristic curve (AUC) and summaries of the confusion matrix (sensitivity and specificity) were used as performance metrics for the prediction outputs of the CNN.

Results

Images from 236 eyes of 129 cognitively normal subjects and 154 eyes of 80 MCI subjects were used for training, validating, and testing the CNN. When applied to the independent test set using inputs including GC-IPL thickness maps, OCTA images, and quantitative OCT and OCTA data, the AUC value for the CNN was 0.809 (95% confidence interval [CI]: 0.681-0.937). This model achieved a sensitivity of 79% and specificity of 83%. The AUC value for GC-IPL thickness maps alone was 0.681 (95% CI: 0.529-0.832), for OCTA images alone was 0.625 (95% CI: 0.466-0.784) and for both GC-IPL maps and OCTA images was 0.693 (95% CI: 0.543-0.843). Models using quantitative data alone were also tested, with a model using quantitative data derived from images, 0.960 (95% CI: 0.902-1.00), outperforming a model using demographic data alone, 0.580 (95% CI: 0.417-0.742).

Conclusions

This novel CNN was able to identify an MCI diagnosis using an independent test set comprised of OCT and OCTA images and quantitative data. The GC-IPL thickness maps provided more useful decision support than the OCTA images. The addition of quantitative data inputs also provided significant decision support to the CNN to identify individuals with MCI. Quantitative imaging metrics provided superior decision support than demographic data.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Incident glaucoma and ocular hypertension after periocular and intravitreal steroid injections: a claims-based analysis

BACKGROUND/AIMS

This study aims to determine the incidence and risk of open-angle glaucoma or ocular hypertension (OHT) following ocular steroid injections using healthcare claims data.

METHODS

We retrospectively reviewed deidentified insurance claims data from the IBM MarketScan Database to identify 19 156 adult patients with no prior history of glaucoma who received ocular steroid injections between 2011 and 2020. Patient demographics and steroid treatment characteristics were collected. Postinjection glaucoma/OHT development was defined as a new diagnosis of glaucoma/OHT, initiation of glaucoma drops, and/or surgical or laser glaucoma treatment. Cox proportional hazards models were used to determine the risk of glaucoma/OHT development within 5 years after first steroid injection.

RESULTS

Overall, 3932 (20.5%) patients were diagnosed with new glaucoma/OHT, 3345 (17.5%) started glaucoma drops and 435 (2.27%) required a laser or surgical glaucoma procedure within 5 years of first steroid injection. Triamcinolone subconjunctival injections were associated with a lower risk of glaucoma/OHT development than retrobulbar or intravitreal steroid injections (p<0.001, HR 0.68, 95% CI 0.59 to 0.79), whereas the 0.59 mg fluocinolone acetonide intravitreal implant had the highest risk of glaucoma/OHT development (p=0.001, HR 2.01, 95% CI 1.34 to 3.02). The risk of glaucoma/OHT development was also higher for patients receiving multiple steroid injections (p<0.001), with the largest increase in risk occurring after three total steroid injections.

CONCLUSION

Patients receiving ocular steroid injections are at risk of developing glaucoma/OHT, even with no prior glaucoma/OHT diagnosis or treatment. Patients should be closely monitored for the development of glaucoma following ocular steroid injections, particularly in the setting of intravitreal and/or repeated steroid administration.

Longitudinal Analysis of Retinal Microvascular and Choroidal Imaging Parameters in Parkinson's Disease Compared with Controls

Purpose

To quantify rate of change of retinal microvascular and choroidal structural parameters in subjects with Parkinson's disease (PD) compared with controls using OCT and OCT angiography (OCTA).

Design

Prospective longitudinal study.

Participants

Seventy-four eyes of 40 participants with PD and 149 eyes of 78 control individuals from the Eye Multimodal Imaging in Neurodegenerative Disease database.

Methods

Subjects underwent OCT and OCTA imaging at 2 time points approximately 12 months apart.

Main Outcome Measures

Imaging parameters included central subfield thickness, ganglion cell-inner plexiform layer (GC-IPL) thickness, peripapillary retinal nerve fiber layer thickness, choroidal vascularity index, superficial capillary plexus perfusion density (PFD), vessel density (VD), and foveal avascular zone area.

Results

Participants with PD had greater rate of yearly decrease in GC-IPL (PD = -0.403μm, control = + 0.128 μm; P = 0.01), greater yearly decline in PFD in the 3 × 3 mm ETDRS circle (PD = -0.016, control = + 0.002; P < 0.001) and ring (PD = -0.016, control = + 0.002; P < 0.001); 6 × 6 mm ETDRS circle (PD = -0.021, control = 0.00; P = 0.001), and outer ring (PD = -0.022, control = 0.00; P = 0.001). Participants with PD had greater rate of yearly decline in VD in 3 × 3 mm circle (PD = -0.939/mm, control = + 0.006/mm; P < 0.001) and ring (PD = -0.942/mm, control = + 0.013/mm; P < 0.001); 6 × 6 mm circle (PD = -0.72/mm, control = -0.054/mm; P = 0.006), and outer ring (PD = -0.746/mm, control = -0.054/mm; P = 0.005). When stratified by PD severity based on Hoehn and Yahr stage, faster rates of decline were seen in Hoehn and Yahr stages 3 to 4 in the 3 × 3 mm circle PFD and VD as well as 3 × 3 mm ring VD.

Conclusions

Individuals with PD experience more rapid loss of retinal microvasculature quantified on OCTA and more rapid thinning of the GC-IPL than controls. There may be more rapid loss in patients with greater disease severity.

Financial Disclosures

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

GLP-1 receptor agonists and diabetic retinopathy: A meta-analysis of randomized clinical trials

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are used to treat type 2 diabetes mellitus. Recent research suggests that GLP-1 RAs may influence diabetic retinopathy (DR). We searched ClinicalTrials.gov for trials comparing FDA-approved GLP-1 RAs to placebo, insulin, or oral antidiabetic medicine. Rates of DR, ocular adverse events, demographics, and clinical characteristics were compared amongst cohorts on 93 trials. GLP-1 RA use was significantly associated with increased risk of early-stage DR (risk ratio (RR) = 1.31, 95% confidence interval (CI) [1.01, 1.68]) and early-stage retinal adverse events (RR = 1.29, 95% CI [1.01, 1.66]) compared to placebo. Compared to insulin, GLP-1 RA use protected against late-stage DR (RR = 0.38, 95% CI [0.15, 0.98]). Analysis of individual GLP-1 RAs showed that albiglutide is responsible for these trends, as it is significantly associated with a higher risk of early-stage DR (RR = 2.18, 95% CI [1.01, 4.67]) compared to placebo and a lower risk of late-stage DR (RR = 0.25, 95% CI [0.09, 0.70]) compared to insulin. Albiglutide similarly affected retinal and ocular adverse events. Demographic analysis revealed significant differences between GLP-1 RA and comparator groups for age, HbA1c, body weight, BMI, duration of diabetes, sex, race, and ethnicity. The influence of GLP-1 RAs on DR and the eye may depend on the specific GLP-1 RA and patient demographic and clinical characteristics.

Herpetic anterior uveitis following COVID-19 vaccines: a case series

Purpose

To report a case series of herpetic uveitis following COVID-19 vaccinations.

Methods

Demographic, clinical and treatment-related data of herpetic anterior uveitis cases was collected at five tertiary eye hospitals between January 2021 and June 2022. A retrospective database review at one of the centers comparing the number of cases of herpetic eye disease before and after the introduction of COVID-19 vaccination was performed as well.

Results

Twenty-four patients (9 female, 15 male) with a mean age of 54 years (range 28-83 years) were diagnosed with herpetic uveitis, reporting an onset of symptoms 3-42 days after the first, second or third dose of COVID-19 vaccination. Median time between vaccination and onset of herpetic eye disease was 10 days (mean 12.7 ± 10.15 days) days. The administered vaccines were BNT162b2, mRNA-1273, BBIBP-CorV and Ad26.COV2.S. The cases included 11 HSV, 10 VZV and 1 CMV anterior uveitis, 2 were not further specified. There was an equal number of first episodes (n = 12, 50%) and recurrent episodes (n = 12, 50%). Response to established regimens was generally good. The retrospective database review revealed the exact same incidence of herpetic uveitis during the pandemic and ongoing vaccination compared to prior SARS-CoV-2.

Conclusion

This report includes 24 cases of herpetic anterior uveitis in a temporal relationship to various COVID-19 vaccines. This study supports the potential risk of herpetic eye disease following COVID-19 vaccines, but proof of a direct, causal relationship is missing.

Bilateral Panuveitis in an Adolescent with Autoimmune Lymphoproliferative Syndrome Due to CTLA4 Haploinsufficiency

PURPOSE

To describe a case of bilateral panuveitis in an 11-year-old girl with autoimmune lymphoproliferative syndrome (ALPS) due to CTLA4 haploinsufficiency.

CASE DESCRIPTION

A 5-year-old girl developed cervical adenopathy, and autoimmune hemolytic anemia and thrombocytopenia consistent with Evan's Syndrome. She was subsequently diagnosed with autosomal dominant CTLA4 haploinsuffciency and treated with immunosuppressants. Ocular symptoms developed 6 years later when she complained of blurry vision and photophobia. There were 3+ anterior chamber cells and 1+ flare, stellate keratic precipitates, and 3+ vitreous cells in both eyes. On fluorescein angiography, there was staining along the arcades and peripheral perivascular leakage in both eyes. On indocyanine green angiography, there were hypofluorescent spots throughout the posterior pole. The inflammation was partially responsive to topical and oral corticosteroids.

CONCLUSION

Panuveitis may be associated with ALPS due to CTLA4 haploinsufficiency. Retinal and choroidal involvement should be assessed when anterior chamber inflammation is the presenting sign.

VISUAL AND ANATOMICAL CHANGES AFTER DRUG CESSATION IN PENTOSAN POLYSULFATE SODIUM-ASSOCIATED MACULOPATHY

PURPOSE

The purpose of this study was to describe a case of development of pentosan polysulfate sodium (PPS)-related maculopathy that exhibited potential improvement in imaging findings after drug cessation.

METHODS

This study is a case report.

RESULTS

A 66-year-old woman presented with progressive pigmentary maculopathy associated with long-term PPS usage, including development of a choroidal neovascular membrane in her right eye. After discontinuation of PPS, her clinical course was notable for partial subjective and objective improvement in visual acuity, as well as partial improvement in outer retinal architecture on ocular coherence tomography, but persistence of retinal pigment epithelium atrophy and autofluorescence changes.

CONCLUSION

The course of retinopathy after discontinuation of PPS has yet to be fully determined and has so far been suggested to be progressive. Anatomical improvements seen in our case suggest that further investigations are warranted to determine whether there is potential for partial reversal of some changes in PPS maculopathy.

Autoimmune Inflammatory Eye Disease: Demystifying Clinical Presentations for the Internist

PURPOSE OF REVIEW

Provide a framework for recognizing key symptoms and clinical findings in patients with autoimmune inflammatory eye disease.

RECENT FINDINGS

The most common manifestations of autoimmune inflammatory eye disease are episcleritis, scleritis, uveitis (anterior, intermediate, posterior, and panuveitis), and keratoconjunctivitis sicca. Etiologies can be idiopathic or in association with a systemic autoimmune condition. Referral of patients who may have scleritis is critical for patients presenting with red eyes. Referral of patients who may have uveitis is critical for patients presenting often with floaters and vision complaints. Attention should also be directed to aspects of the history that might suggest a diagnosis of a systemic autoimmune condition, immunosuppression, drug-induced uveitis, or the possibility of a masquerade condition. Infectious etiologies should be ruled out in all cases. Patients with autoimmune inflammatory eye disease may present with ocular or systemic symptoms alone, or in combination. Collaboration with ophthalmologists and other relevant specialists is vital to optimal long-term medical care.

DELAYED ONSET Cutibacterium (FORMERLY Propionibacterium ) acnes ENDOPHTHALMITIS TRIGGERED BY INTRAVITREAL STEROID INJECTION

PURPOSE

We report a case of delayed onset Cutibacterium acnes ( C. acnes , formerly Propionibacterium acnes or P. acnes ) endophthalmitis with the onset triggered by intravitreal steroid injection (triamcinolone acetonide) in a pseudophakic patient, 7 years after cataract surgery.

METHODS/PATIENTS

A 67-year-old man presented with gradual worsening of vision, eye redness, and photosensitivity that started a month after intravitreal triamcinolone acetonide injection (Triescience, 4 mg/0.1 mL, Alcon Labs, Fort Worth, TX) for cystoid macular edema secondary to branch retinal vein occlusion in the right eye. The patient had undergone cataract surgery with intraocular lens in that eye 7 years prior. Examination showed the visual acuity of counting fingers at 3 feet and conjunctival injection, with 2+ anterior chamber cell and 2+ vitreous haze. Uveitis work up including angiotensin-converting enzyme, QuantiFERON Gold, and syphilis IgG screen was negative. Diagnostic pars plana vitrectomy with intravitreal injection of antibiotics was performed, and vitreous sample was sent for detailed laboratory analysis.

RESULTS

Vitreous fluid analysis was positive for C. acnes and negative for viral, fungal, and malignant cells. Although the patient received intravitreal antibiotics injection twice, the intraocular infection and inflammation persisted which eventually required an intraocular lens and capsular bag removal, followed by insertion of a secondary intraocular lens later.

CONCLUSION

Delayed onset C. acnes endophthalmitis may be triggered by an intravitreal steroid injection in pseudophakic patients.

Intrasession Repeatability of OCT Angiography Parameters in Neurodegenerative Disease

Purpose

To assess the intrasession repeatability of macular OCT angiography (OCTA) parameters in Alzheimer's disease (AD), mild cognitive impairment (MCI), Parkinson's disease (PD), and normal cognition (NC).

Design

Cross sectional study.

Subjects

Patients with a clinical diagnosis of AD, PD, MCI, or NC were imaged. Images with poor quality and of those with diabetes mellitus, glaucoma, or vitreoretinal disease were excluded from analysis.

Methods Intervention or Testing

All participants were imaged using the Zeiss Cirrus HD-5000 with AngioPlex (Carl Zeiss Meditec, Software Version 11.0.0.29946) and repeat OCTA images were obtained for both eyes. Perfusion density (PFD), vessel density (VD), and Foveal avascular zone (FAZ) area were measured from 3 × 3 mm and 6 × 6 mm OCTA images centered on the fovea using an ETDRS grid overlay.

Main Outcome Measures

Intraclass correlation coefficients were used to quantify repeatability of PFD, VD, and FAZ area measurements obtained from imaging.

Results

3 × 3 mm scans of 22 AD, 40 MCI, 21 PD, and 26 NC participants and 6 × 6 mm scans of 29 AD, 44 MCI, 29 PD, and 30 NC participants were analyzed. Repeatability values ranged from 0.64 (0.49-0.82) for 6 × 6 mm PFD in AD participants to 0.87 (0.67-0.92) for 3 × 3 mm PFD in AD participants. No significant differences were observed in repeatability between NC participants and those with neurodegenerative disease.

Conclusions

Overall, similar OCTA repeatability was observed between NC participants and those with neurodegeneration. Regardless of diagnostic group, macular OCTA metrics demonstrated moderate to good repeatability.

Financial Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

Convolutional Neural Network-Based Automated Quality Assessment of OCT and OCT Angiography Image Maps in Individuals With Neurodegenerative Disease

Purpose

To train and test convolutional neural networks (CNNs) to automate quality assessment of optical coherence tomography (OCT) and OCT angiography (OCTA) images in patients with neurodegenerative disease.

Methods

Patients with neurodegenerative disease were enrolled in the Duke Eye Multimodal Imaging in Neurodegenerative Disease Study. Image inputs were ganglion cell-inner plexiform layer (GC-IPL) thickness maps and fovea-centered 6-mm × 6-mm OCTA scans of the superficial capillary plexus (SCP). Two trained graders manually labeled all images for quality (good versus poor). Interrater reliability (IRR) of manual quality assessment was calculated for a subset of each image type. Images were split into train, validation, and test sets in a 70%/15%/15% split. An AlexNet-based CNN was trained using these labels and evaluated with area under the receiver operating characteristic (AUC) and summaries of the confusion matrix.

Results

A total of 1465 GC-IPL thickness maps (1217 good and 248 poor quality) and 2689 OCTA scans of the SCP (1797 good and 892 poor quality) served as model inputs. The IRR of quality assessment agreement by two graders was 97% and 90% for the GC-IPL maps and OCTA scans, respectively. The AlexNet-based CNNs trained to assess quality of the GC-IPL images and OCTA scans achieved AUCs of 0.990 and 0.832, respectively.

Conclusions

CNNs can be trained to accurately differentiate good- from poor-quality GC-IPL thickness maps and OCTA scans of the macular SCP.

Translational Relevance

Since good-quality retinal images are critical for the accurate assessment of microvasculature and structure, incorporating an automated image quality sorter may obviate the need for manual image review.

0.18 MG FLUOCINOLONE ACETONIDE INSERT FOR THE TREATMENT OF CHRONIC POSTOPERATIVE PSEUDOPHAKIC CYSTOID MACULAR EDEMA

PURPOSE

To report the outcomes of the 0.18 mg fluocinolone acetonide insert (FAi) in the treatment of chronic (>6 months) postoperative cystoid macular edema after cataract surgery.

METHODS

This was a retrospective consecutive case series of eyes with chronic postoperative cystoid macular edema treated with the FAi. Visual acuity, intraocular pressure, optical coherence tomography metrics, and supplemental therapies were extracted from the charts before and at 3, 6, 12, 18, and 21 months after FAi placement, when available.

RESULTS

Nineteen eyes of 13 patients with chronic postoperative cystoid macular edema after cataract surgery underwent FAi placement with an average follow-up of 15.4 months. Ten eyes (52.6%) had a ≥2-line gain in visual acuity. Sixteen eyes (84.2%) had a ≥20% reduction in optical coherence tomography central subfield thickness. Eight eyes (42.1%) had complete resolution of CME. Improvements in central subfield thickness and visual acuity were sustained throughout individual follow-up. Compared with 18 eyes (94.7%) requiring local corticosteroid supplementation before FAi, only six eyes (31.6%) required supplementation after FAi. Similarly, of the 12 eyes (63.2%) that were on corticosteroid drops before FAi, only 3 (15.8%) required drops after FAi.

CONCLUSION

Eyes with chronic postoperative cystoid macular edema after cataract surgery treated with the FAi had improved and sustained visual acuity and optical coherence tomography metrics, along with a reduction in supplemental treatment burden.

Stepwise approach for fundus imaging in the diagnosis and management of posterior uveitis

An array of retinochoroid imaging modalities aid in comprehensive evaluation of the immunopathological changes in the retina and choroid, forming the core component for the diagnosis and management of inflammatory disorders such as uveitis. The recent technological breakthroughs have led to the development of imaging platforms that can evaluate the layers of retina and choroid and the structural and functional alteration in these tissues. Ophthalmologists heavily rely on imaging modalities such as dye-based angiographies (fluorescein angiography and indocyanine green angiography), optical coherence tomography, fundus autofluorescence, as well as dye-less angiography such as optical coherence tomography angiograph,y for establishing a precise diagnosis and understanding the pathophysiology of the diseases. Furthermore, these tools are now being deployed with a 'multimodal' approach for swift and accurate diagnosis. In this comprehensive review, we outline the imaging platforms used for evaluation of posterior uveitis and discuss the organized, algorithmic approach for the assessment of the disorders. Additionally, we provide an insight into disease-specific characteristic pathological changes and the established strategies to rule out disorders with overlapping features on imaging.

Retinal Vascular Changes in Alzheimer's Dementia and Mild Cognitive Impairment: A Pilot Study Using Ultra-Widefield Imaging

Purpose

Retinal microvascular abnormalities measured on retinal images are a potential source of prognostic biomarkers of vascular changes in the neurodegenerating brain. We assessed the presence of these abnormalities in Alzheimer's dementia and mild cognitive impairment (MCI) using ultra-widefield (UWF) retinal imaging.

Methods

UWF images from 103 participants (28 with Alzheimer's dementia, 30 with MCI, and 45 with normal cognition) underwent analysis to quantify measures of retinal vascular branching complexity, width, and tortuosity.

Results

Participants with Alzheimer's dementia displayed increased vessel branching in the midperipheral retina and increased arteriolar thinning. Participants with MCI displayed increased rates of arteriolar and venular thinning and a trend for decreased vessel branching.

Conclusions

Statistically significant differences in the retinal vasculature in peripheral regions of the retina were observed among the distinct cognitive stages. However, larger studies are required to establish the clinical importance of our findings. UWF imaging may be a promising modality to assess a larger view of the retinal vasculature to uncover retinal changes in Alzheimer's disease.

Translational Relevance

This pilot work reports an investigation into which retinal vasculature measurements may be useful surrogate measures of cognitive decline, as well as technical developments (e.g., measurement standardization), that are first required to establish their recommended use and translational potential.

Artificial intelligence in dementia

PURPOSE OF REVIEW

Artificial intelligence tools are being rapidly integrated into clinical environments and may soon be incorporated into dementia diagnostic paradigms. A comprehensive review of emerging trends will allow physicians and other healthcare providers to better anticipate and understand these powerful tools.

RECENT FINDINGS

Machine learning models that utilize cerebral biomarkers are demonstrably effective for dementia identification and prediction; however, cerebral biomarkers are relatively expensive and not widely available. As eye images harbor several ophthalmic biomarkers that mirror the state of the brain and can be clinically observed with routine imaging, eye-based machine learning models are an emerging area, with efficacy comparable with cerebral-based machine learning models. Emerging machine learning architectures like recurrent, convolutional, and partially pretrained neural networks have proven to be promising frontiers for feature extraction and classification with ocular biomarkers.

SUMMARY

Machine learning models that can accurately distinguish those with symptomatic Alzheimer's dementia from those with mild cognitive impairment and normal cognition as well as predict progressive disease using relatively inexpensive and accessible ocular imaging inputs are impactful tools for the diagnosis and risk stratification of Alzheimer's dementia continuum. If these machine learning models can be incorporated into clinical care, they may simplify diagnostic efforts. Recent advancements in ocular-based machine learning efforts are promising steps forward.

Impact of COVID-19-related lockdown on retinal disorders treated with intravitreal injections

PURPOSE

To study functional changes in vision and morphological changes on optical coherence tomography (OCT) scans in patients where intravitreal therapy (IVT) with injections has been delayed due to COVID-19 pandemic lockdown.

METHODS

Retrospective cross-sectional study included 77 eyes with the diagnosis of exudative age-related macular degeneration (eAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO), regularly receiving IVT with anti-vascular endothelial growth factor (Anti-VEGF) injections or dexamethasone implant and were not able to receive the injections as intended due to lockdown. Best-corrected visual acuity (BCVA), central foveal thickness (CFT), and qualitative morphological features on OCT were analyzed pre- and post-therapy break off.

RESULTS

The mean duration of IVT break-off was 57 days. Mean BCVA logarithm of minimum angle of resolution (logMAR) worsened from 0.33 (20/42) to 0.35 (40/44) (P = 0.02) and mean CFT increased from 297.90 μm to 402.16 μm (P < 0.01), from pretherapy break-off to return visit. Worsening of the visual acuity was seen across all the three disease cohorts, significantly more in the eyes with eAMD.

CONCLUSION

Marginal decline in the visual acuity and worsening of the OCT features were observed as a result of delay in the IVT injections of DME, eAMD and RVO patients.

INTERMEDIATE UVEITIS WITH RETINAL DETACHMENT IN A PATIENT WITH POMPE DISEASE

PURPOSE

To describe the ocular findings in a patient with glycogen storage disease II (Pompe disease).

METHODS

Case report.

RESULTS

A 14-year-old boy with Pompe disease was referred for evaluation of a retinal detachment in the left eye. Indirect ophthalmoscopy revealed bilateral fibrotic snowbanks and an inferior rhegmatogenous retinal detachment extending into the macula. Fluorescein angiography revealed mild diffuse perivascular leakage in both eyes. The retinal detachment was repaired with scleral buckling and cryotherapy. Workup for the etiology of the intermediate uveitis was unrevealing.

CONCLUSION

Enzyme replacement therapy has improved the survival of individuals with Pompe disease. With greater patient longevity, new ocular associations may continue to emerge. Whether intermediate uveitis is an ocular association of Pompe disease remains to be determined.

Optical Coherence Tomography Anatomic and Temporal Biomarkers in Uveitic Macular Edema

PURPOSE

To assess the relationship between best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) features in noninfectious uveitis (NIU)-related macular edema.

DESIGN

Clinical cohort study from post hoc analysis of 2 phase 3 clinical trials.

METHODS

Correlation and longitudinal treatment analyses were performed. Of 198 patients with NIU, 134 received suprachoroidal CLS-TA (proprietary formulation of a triamcinolone acetonide injectable suspension), and 64 received sham, with 12.9% and 72%, respectively, receiving rescue therapy.

RESULTS

At baseline, mean BCVA progressively worsened with each ordinal drop in central subfield ellipsoid zone (EZ) integrity. Eyes with normal baseline EZ experienced greater 24-week change in BCVA versus those with some degree of baseline EZ disruption (11.9 vs 9.4 letters, P = .006). In contrast, eyes with baseline central subfield cystoid spaces and/or subretinal fluid showed more improvement (13.7 or 17.2 letters, respectively) at 24 weeks, versus those without such findings (5.5 [P = .012] or 9.5 letters [P < .001], respectively). Longitudinal modeling for CLS-TA-treated eyes showed that central subfield thickness (CST) reached 90% of maximal improvement by week 3, whereas 90% maximal response in BCVA was not reached until week 9. CLS-TA-treated eyes that showed CST reduction of ≥50 µm at 4 weeks experienced a greater 24-week improvement in BCVA versus those without such an early response (14.6 vs 6.5 letters, P = .006 for difference).

CONCLUSIONS

Pretreatment EZ integrity and the presence of central subfield cystoid spaces or subretinal fluid each predict improved therapeutic response to treatment in eyes with NIU. In CLS-TA treated eyes, longitudinal modeling shows CST improvement preceding BCVA improvement.

Artificial Intelligence and Imaging Processing in Optical Coherence Tomography and Digital Images in Uveitis

INTRODUCTION

Computer vision, understood as the area of science that trains computers to interpret digital images through both artificial intelligence (AI) and classical algorithms, has significantly advanced the analysis and interpretation of optical coherence tomography (OCT) in retina research. The aim of this review is to summarise the recent advances of computer vision in imaging processing in uveitis, with a particular focus in optical coherence tomography images.

MATERIAL AND METHODS

Literature review.

RESULTS

The development of computer vision to assist uveitis diagnosis and prognosis is still undergoing, but important efforts have been made in the field.

CONCLUSION

The automatising of image processing in uveitis could be fundamental to establish objective and standardised outcomes for future clinical trials. In addition, it could help to better understand the disease and its progression.

Longitudinal analysis of the retina and choroid in cognitively normal individuals at higher genetic risk for Alzheimer disease

PURPOSE

To assess baseline differences and longitudinal rate of change in retinal and choroidal imaging parameters between APOE ε4 carriers and non-carriers with normal cognition.

DESIGN

Prospective study.

SUBJECTS

413 eyes of 218 individuals with normal cognition aged ≥55 years with known APOE status (98 ε4 carriers, 120 non-carriers). Exclusion criteria included diabetes mellitus, uncontrolled hypertension, glaucoma, and vitreoretinal or neurodegenerative disease.

METHODS

Optical coherence tomography (OCT) and OCT angiography (OCTA) was performed at baseline and at 2 years [Zeiss Cirrus HD-OCT 5000 with AngioPlex (Zeiss Meditec, Dublin, CA)]. Groups were compared using sex- and age-adjusted generalized estimating equations.

MAIN OUTCOME MEASURES

OCT: retinal nerve fiber layer thickness, macular ganglion cell-inner plexiform layer thickness, central subfield thickness (CST), choroidal vascularity index. OCTA: foveal avascular zone area, perfusion density (PD), vessel density, peripapillary capillary perfusion density and capillary flux index (CFI). Rate of change per year was calculated.

RESULTS

At baseline, ε4 carriers demonstrated decreased CST (p=0.018), PD in the 6mm Early Treatment Diabetic Retinopathy Study (ETDRS) circle (p=0.049), and temporal CFI (p=0.047). Seventy-one ε4 carriers and 78 non-carriers returned at 2 years; at follow-up, the 6mm ETDRS circle (p=0.05) and outer ring (p=0.049) showed decreased PD in ε4 carriers, with no differences in rates of change between groups (all p>0.05).

CONCLUSIONS

There were measured differences in CST, PD, and peripapillary CFI between APOE ε4 carriers and non-carriers with normal cognition. Larger and longer-term studies may further elucidate the potential prognostic value of these findings.

Mycobacterium chelonae Endogenous Endophthalmitis in a Person Addicted to Intravenous Drugs Presenting as an Intraretinal Peripapillary Granuloma With Tractional Retinal Detachment

Purpose:

To report a case of Mycobacterium chelonae endogenous endophthalmitis in a 28-year-old man with recent intravenous drug use that presented as an intraretinal peripapillary granuloma extending from the optic nerve head with an associated macular tractional retinal detachment.

Methods:

Case report.

Results:

Anterior chamber tap yielded aqueous cultures positive for M chelonae. A diagnostic and therapeutic vitrectomy was performed after inpatient hospitalization for 3 weeks to relieve a progressively worsening tractional retinal detachment.

Conclusions:

Atypical causes of endophthalmitis, including nontuberculous mycobacterium, in the population of individuals addicted to intravenous drugs may present with intraretinal peripapillary granuloma associated with a macular tractional retinal detachment. Surgical debulking to relieve anteroposterior traction is an effective treatment option to improve long-term visual outcomes.

Retinal and Choroidal Changes in Men Compared with Women with Alzheimer’s Disease

Purpose

To evaluate differences in the retinal microvasculature and structure and choroidal structure among men and women with Alzheimer’s disease (AD) compared with age-matched cognitively normal male and female controls.

Design

Case-control study of participants ≥ 50 years of age.

Participants

A total of 202 eyes of 139 subjects (101 cases and 101 controls).

Methods

All participants and controls underwent OCT and OCT angiography (OCTA), and parameters of subjects with AD were compared with those of cognitively normal controls.

Main Outcome Measures

The foveal avascular zone (FAZ) area, vessel density (VD), and perfusion density (PD) in the superficial capillary plexus within the 3- and 6-mm circle and ring using Early Treatment Diabetic Retinopathy Study (ETDRS) grid overlay on OCTA; central subfield thickness (CST), retinal nerve fiber layer (RNFL) thickness, ganglion cell-inner plexiform layer (GCIPL) thickness, and choroidal vascularity index (CVI) on OCT.

Results

No significant sex differences in VD or PD were found in the AD or control cohorts; however, there were greater differences in VD and PD among AD female participants than AD male participants compared with their respective controls. The CST and FAZ area were not different between male and female AD participants. Among controls, men had a thicker CST (P < 0.001) and smaller FAZ area (P = 0.003) compared with women. The RNFL thickness, GCIPL thickness, and CVI were similar among male and female AD participants and controls.

Conclusions

There may be a loss of the physiologic sex-related differences in retinal structure and microvasculature in those with AD compared with controls. Further studies are needed to elucidate the pathophysiological basis for these findings.

Consensus-based recommendations for optical coherence tomography angiography reporting in uveitis

BACKGROUND/AIMS

To establish a consensus in the nomenclature for reporting optical coherence tomography angiography (OCTA findings in uveitis.

METHODS

The modified Delphi process consisted of two rounds of electronic questionnaires, followed by a face-to-face meeting conducted virtually. Twenty-one items were included for discussion. The three main areas of discussion were: wide field OCTA (WF-OCTA), nomenclature of OCTA findings and OCTA signal attenuation assessment and measurement. Seventeen specialists in uveitis and retinal imaging were selected by the executive committee to constitute the OCTA nomenclature in Uveitis Delphi Study Group. The study endpoint was defined by the degree of consensus for each question: 'strong consensus' was defined as >90% agreement, 'consensus' as 85%-90% and 'near consensus' as >80% but <85%.

RESULTS

There was a strong consensus to apply the term 'wide field' to OCTA images measuring over 70° of field of view, to use the terms 'flow void' and 'non-detectable flow signal' to describe abnormal OCTA flow signal secondary to vessels displacement and slow flow respectively, to use the terms 'loose' and 'dense' to describe the appearance of inflammatory choroidal neovascularisation, and to use the percentage of flow signal decrease to measure OCTA ischaemia with a threshold greater than or equal to 30% as a 'large area'.

CONCLUSIONS

This study sets up consensus recommendations for reporting OCTA findings in uveitis by an expert panel, which may prove suitable for use in routine clinical care and clinical trials.

CLINICAL CHARACTERISTICS AND VISUAL OUTCOMES IN ENDOPHTHALMITIS AFTER KERATOPROSTHESIS IMPLANTATION

PURPOSE

To describe the presentation, microbiology, management, and prognosis of eyes with endophthalmitis after Boston keratoprosthesis implantation.

METHODS

Retrospective case series with history, diagnostics, management, and outcomes data in endophthalmitis after keratoprosthesis implantation presenting to a tertiary center between 2009 and 2020.

RESULTS

Of 137 keratoprosthesis-implanted eyes, 7 eyes of 7 patients (5%) developed endophthalmitis. On presentation, 6 (86%) reported decreased visual acuity, and only 1 (14%) reported pain. Peripheral corneal ulcers were present in 2 eyes (29%). Seidel testing was negative in all cases. Six eyes (86%) had retroprosthetic membranes. One (14%) underwent initial pars plana vitrectomy with mechanical vitreous biopsy, whereas 6 (86%) received a needle vitreous tap-half of which were dry. Organisms were isolated after vitreous tap in two eyes: Streptococcus intermedius and Mycobacterium abscessus. The mean visual acuity preendophthalmitis, at presentation, and at 6 months were 20/267, 20/5,944, and 20/734, respectively. The visual acuity improved 9.08 ± 11.78 Early Treatment Diabetic Retinopathy Study lines from presentation to 6 months. Six-month visual acuity was correlated with preendophthalmitis visual acuity (r = 0.92, P = 0.003) but not presenting visual acuity (P = 0.838).

CONCLUSION

Visual acuity at 6 months is correlated with preendophthalmitis visual acuity, not presenting visual acuity. Endophthalmitis should be considered in the differential diagnosis of painless intraocular inflammation any time after keratoprosthesis implantation, even if Seidel negative.

Choroidal Imaging in uveitis: an update

An important goal of advancements in ocular imaging algorithms and devices has been to improve the image acquisition and resolution of deeper ocular tissues, namely the choroid and its vasculature that are otherwise inaccessible to direct clinical examination. These advancements have contributed to the understanding of the pathophysiology of a number of ocular inflammatory conditions. We focuse on the imaging characteristics of clinical conditions where imaging the choroid has improved or radically changed the understanding of the disease, has helped in differentiation of phenotypically similar but distinct lesions, and where imaging features have proven vital formonitoring disease activity. The last two decades have seen some major developments in ocular imaging relevant to uveitis. The current review addresses both the imaging characteristics and their interpretation on conventional modalities such as fundus photography, fluorescein angiography, indocyanine green angiography and fundus autofluorescence and the recent additions in the armamentarium including optical coherence tomography (OCT) with enhanced depth imaging, swept-source OCT, and OCT angiography.

Multimodal imaging of type 2 acute macular neuroretinopathy in a young woman

We report a case of type 2 acute macular neuroretinopathy (AMN) that occurred in an otherwise healthy 22-year-old white woman taking oral contraceptives and consuming large quantities of caffeinated coffee. The patient presented with a teardrop-shaped scotoma just inferior to her central vision in her left eye after a recent and significant increase in coffee consumption. A small extrafoveal retinal lesion was present superior to the fovea on pseudocolor fundus photography. Multimodal retinal imaging demonstrated focal disruption of the inner segment-outer segment junction of the photoreceptors with overlying hyperreflectivity at the level of the outer plexiform layer superior to the fovea, consistent with a diagnosis of type 2 AMN. Oral contraceptive use and high caffeine intake may be risk factors for the development of type 2 AMN.

Repeatability of Peripapillary OCT Angiography in Neurodegenerative Disease

Purpose

To assess the repeatability of peripapillary OCT angiography (OCTA) in those with Alzheimer disease (AD), mild cognitive impairment (MCI), Parkinson disease (PD), or normal cognition.

Design

Cross-sectional.

Participants

Patients with a clinical diagnosis of AD, MCI, PD, or normal cognition were imaged. Those with glaucoma, diabetes mellitus, vitreoretinal pathology, and poor-quality images were excluded.

Methods

Each eligible eye of each participant underwent 2 OCTA 4.5 × 4.5-mm peripapillary scans in a single session using a Zeiss Cirrus HD-OCT 5000 with AngioPlex (Carl Zeiss Meditec). The Zeiss software (v11.0.0.29946) quantified measures of perfusion in the radial peripapillary capillary (RPC) plexus in 4 sectors (superior, nasal, inferior, temporal). The average of these sectors was calculated and reported.

Main Outcome Measures

Radial peripapillary capillary plexus perfusion was quantified using 2 parameters: capillary perfusion density (CPD) and capillary flux index (CFI). Intraclass correlation coefficients (ICCs) were used to quantify repeatability. For subjects who had both eyes included, the average values of each scan pair were used to assess interocular symmetry of CPD and CFI.

Results

Of 374 eyes, 46 were from participants who had AD, 85 were from participants who had MCI, 87 were from participants who had PD, and 156 were from participants who had normal cognition. Capillary perfusion density ICC in AD = 0.88 (95% confidence interval [CI], 0.79–0.93), MCI = 0.95 (0.92–0.96), PD = 0.91 (0.87–0.94), and controls = 0.90 (0.87–0.93). Capillary flux index ICC in AD = 0.82 (0.70–0.90), MCI = 0.87 (0.80–0.91), PD = 0.91 (0.87–0.94) and controls = 0.85 (0.79–0.89). There were no significant differences in interocular variation in average CPD and CFI in AD, MCI, or PD (all P > 0.05). Isolated interocular sectoral CPD differences were noted in AD (nasal, P = 0.049; temporal, P = 0.024), PD (nasal, P = 0.036), and controls (nasal, P = 0.016). Interocular differences in CFI in the superior sector in MCI (P = 0.028) and in average CFI for controls (P = 0.035) were observed.

Conclusions

Peripapillary OCTA repeatability in AD, MCI, and PD is good-excellent and similar to those with normal cognition. Insignificant interocular asymmetry in peripapillary OCTA suggests neurodegeneration may proceed uniformly; future studies may reveal the appropriateness of single-eye imaging.

SARILUMAB FOR RECALCITRANT CYSTOID MACULAR EDEMA IN NON-PARANEOPLASTIC AUTOIMMUNE RETINOPATHY

PURPOSE

To demonstrate a rapid improvement of recalcitrant cystoid macular edema (CME) and perivascular leakage, in a patient with non-paraneoplastic autoimmune retinopathy and autoimmune optic neuropathy after treatment with sarilumab, a human anti-interleukin-6 (IL-6) receptor antibody.

METHODS

Observational case report.

RESULTS

A 29-year-old woman was diagnosed with non-paraneoplastic autoimmune retinopathy and autoimmune optic neuropathy and followed over 1.5 years. She had recalcitrant CME despite local corticosteroid and immunosuppressive therapy that included azathioprine and adalimumab. Subcutaneous sarilumab was initiated at a dose of 200 mg every 2 weeks. Cystoid macular edema significantly decreased after two injections and resolved after four injections with associated improvement in visual acuity and significant improvement in perivascular leakage on fluorescein angiography. There was a sustained visual and anatomical improvement at 6 months along with mild improvement in electroretinogram responses. The patient tolerated the medication with no side effects.

CONCLUSION

Management of CME in non-paraneoplastic autoimmune retinopathy is challenging, and long-term immunosuppression is often employed with varying degrees of success. The improvement in refractory CME and perivascular leakage in this case supports the potential role of an IL-6 inhibitor to treat CME associated with non-paraneoplastic autoimmune retinopathy suggesting the role.

Anti-Interleukin-6 Antibodies for Autoimmune Retinopathy with Macular Edema

In this cohort of patients with non-paraneoplastic autoimmune retinopathy and cystoid macular edema (CME), treatment with anti-interleukin-6 antibodies was associated with reduced CME, partial restoration of the ellipsoid zone on optical coherence tomography, and a trend towards improved visual acuity.

Assessing the Retinal Microvasculature in Individuals With Early and Late-Onset Alzheimer's Disease

BACKGROUND AND OBJECTIVE

To evaluate retinal microvascular changes in early and late-onset Alzheimer's disease (AD).

PATIENTS AND METHODS

Eighty-six eyes of 50 late-onset AD participants, 27 eyes of 15 early onset AD participants, and 111 eyes of 57 cognitively normal controls were included. Optical coherence tomography angiography (OCTA) vessel density (VD) and perfusion density (PD) in Early Treatment Diabetic Retinopathy Study 3-mm and 6-mm circles and rings were assessed.

RESULTS

There was decreased PD in early onset AD 3-mm circle (P = .026) and ring (P = .026) versus controls as well as in late-onset AD 3-mm circle (P = .023) and ring (P = .023) versus controls. There was decreased VD in late-onset AD 3-mm circle (P = .012) and ring (P = .006). No parameters differed between early and late-onset AD (P > .05).

CONCLUSIONS

AD eyes exhibited decreased retinal microvascular density compared to controls. Retinal parameters may not differ between early onset AD and late-onset AD after adjusting for age. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:336-344.].

Frequency of Urgent or Emergent Vitreoretinal Surgical Procedures in the United States During the COVID-19 Pandemic

Importance

The American Academy of Ophthalmology (AAO) indicated that urgent or emergent vitreoretinal surgical procedures should continue during the coronavirus disease 2019 (COVID-19) pandemic. Although decreases in the frequency of critical procedures have been reported outside the field of ophthalmology, analyses are limited by volume, geography, and time.

Objective

To evaluate whether the frequency of ophthalmic surgical procedures deemed urgent or emergent by the AAO changed across the United States during the COVID-19 pandemic.

Design, Setting, and Participants

Vitreoretinal practices from 17 institutions throughout the US participated in this multicenter cross-sectional study. The frequency of 11 billed vitreoretinal Current Procedural Terminology (CPT) codes across respective weeks was obtained from each practice between January 1, 2019, and May 31, 2020. Data were clustered into intravitreal injections (code 67028), lasers and cryotherapy (codes 67141, 67145, and 67228), retinal detachment (RD) repairs (codes 67107, 67108, 67110, and 67113), and other vitrectomies (codes 67036, 67039, and 67040). Institutions were categorized by region (Northeast, Midwest, South, and West Coast), practice setting (academic [tax-exempt] or private [non-tax-exempt]), and date of respective statewide stay-at-home orders.

Main Outcomes and Measures

Nationwide changes in the frequency of billing for urgent or emergent vitreoretinal surgical procedures during the COVID-19 pandemic.

Results

A total of 526 536 CPT codes were ascertained: 483 313 injections, 19 257 lasers or cryotherapy, 14 949 RD repairs, and 9017 other vitrectomies. Relative to 2019, a weekly institutional decrease in injections was observed from March 30 to May 2, 2020, with a maximal 38.6% decrease (from a mean [SD] of 437.8 [436.3] to 273.8 [269.0] injections) from April 6 to 12, 2020 (95% CI, -259 to -69 injections; P = .002). A weekly decrease was also identified that spanned a longer interval, at least until study conclusion (March 16 to May 31, 2020), for lasers and cryotherapy, with a maximal 79.6% decrease (from a mean [SD] of 6.6 [7.7] to 1.5 [2.0] procedures) from April 6 to 12, 2020 (95% CI, -6.8 to -3.3 procedures; P < .001), for RD repairs, with a maximal 59.4% decrease (from a mean [SD] of 3.5 [4.0] to 1.6 [2.2] repairs) from April 13 to 19, 2020 (95% CI, -2.7 to -1.4 repairs; P < .001), and for other vitrectomies, with a maximal 84.3% decrease (from a mean [SD] of 3.0 [3.1] to 0.4 [0.8] other vitrectomies) from April 6 to 12, 2020 (95% CI, -3.3 to -1.8 other vitrectomies; P < .001). No differences were identified by region, setting, or state-level stay-at-home order adjustment.

Conclusions and Relevance

Although the AAO endorsed the continued performance of urgent or emergent vitreoretinal surgical procedures, the frequency of such procedures throughout the country experienced a substantial decrease that may persist after the COVID-19 pandemic's initial exponential growth phase. This decrease appears independent of region, setting, and state-level stay-at-home orders. It is unknown to what extent vitreoretinal intervention would have decreased without AAO recommendations, and how the decrease is associated with outcomes. Although safety is paramount during the COVID-19 pandemic, practices should consider prioritizing availability for managing high-acuity conditions until underlying reasons for the reduction are fully appreciated.

Repeatability of Peripapillary Optical Coherence Tomography Angiography Parameters in Older Adults

Purpose:

This work assesses the intrasession repeatability of capillary perfusion density (CPD) and capillary flux index (CFI) measurements on peripapillary optical coherence tomography angiography (OCTA) in healthy eyes of older adults.

Methods:

In this cross-sectional study, healthy volunteers aged 50 years or older underwent 4.5 × 4.5 mm OCTA imaging centered on the optic nerve head using Zeiss Cirrus HD-5000 AngioPlex (Carl Zeiss Meditec). Two consecutive images were acquired in the same eye during a single study session. CPD and CFI were assessed using AngioPlex Software (version 11.0.0.29946) for the radial peripapillary capillary plexus (average over whole scan area) and 4 quadrants (superior, inferior, temporal, and nasal). CPD and CFI repeatability was assessed by intraclass correlation (ICC), mean interocular differences using 2-tailed t test, and association with age using generalized estimating equations.

Results:

A total of 150 images were acquired from 75 eyes of 47 patients. For CPD, ICC results ranged from 0.7160 (nasal CPD) to 0.9218 (average CPD). For CFI, ICC results ranged from 0.6167 (temporal CFI) to 0.8976 (inferior CFI). Temporal CFI was significantly different between right and left eyes of the same patient ( P = .03). CPD and CFI decreased with age in all analyses (average CPD β coefficient –0.00172, P < .001; average CFI β coefficient −0.00278, P < .001).

Conclusions:

Moderate to good repeatability was observed for most peripapillary OCTA metrics; temporal measurements were least repeatable for CPD and CFI. Peripapillary CPD and CFI decrease with age even beyond the fifth decade in healthy older adults.

Inpatient Ophthalmology Consultations

Comprehensive patient care requires an integrated approach that often includes different specialties. Of these specialties, Ophthalmology stands out with its variable pathologic conditions, unique tools, and special examination techniques, which are not part of the standard training of internal medicine or other specialties. The authors review prior studies focused on inpatient ophthalmology consultations, common reasons for inpatient ophthalmology consultation, and the recommended approach to the most common ocular complaints that could present to the inpatient provider. They also shed light on the basic ocular history and eye examination that should be obtained before requesting an ophthalmic evaluation.

Characterization of Retinal Microvascular and Choroidal Structural Changes in Parkinson Disease

Importance

Noninvasive retinal imaging may detect structural changes associated with Parkinson disease (PD) and may represent a novel biomarker for disease detection.

Objective

To characterize alterations in the structure and microvasculature of the retina and choroid in eyes of individuals with PD and compare them with eyes of age- and sex-matched cognitively healthy control individuals using optical coherence tomography (OCT) and OCT angiography (OCTA).

Design, Setting, and Participants

This cross-sectional study was conducted at the Duke Neurological Disorders Clinic in Durham, North Carolina. Individuals aged 50 years or older with a diagnosis of PD were eligible for inclusion and underwent an evaluation and diagnosis confirmation before enrollment. Control individuals aged 50 years or older and without subjective cognitive dysfunction, a history of tremor, or evidence of motor dysfunction consistent with parkinsonism were solicited from the clinic or the Duke Alzheimer's Disease Prevention Registry. Individuals with diabetes, glaucoma, retinal pathology, other dementias, and corrected Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity worse than 20/40 Snellen were excluded. Data were analyzed between January 1, 2020, and March 30, 2020.

Exposures

All participants underwent OCT and OCTA imaging.

Main Outcomes and Measures

Generalized estimating equation analysis was used to characterize the association between imaging parameters and PD diagnosis. Superficial capillary plexus vessel density (VD) and perfusion density (PFD) were assessed within the ETDRS 6 × 6-mm circle, 6 × 6-mm inner ring, and 6 × 6-mm outer ring, as was the foveal avascular zone area. Peripapillary retinal nerve fiber layer thickness, macular ganglion cell-inner plexiform layer thickness, central subfield thickness, subfoveal choroidal thickness, total choroidal area, luminal area, and choroidal vascularity index (CVI) were measured.

Results

A total of 124 eyes of 69 participants with PD (39 men [56.5%]; mean [SD] age, 71.7 [7.0] years) and 248 eyes of 137 control participants (77 men [56.2%]; mean [SD] age, 70.9 [6.7] years) were analyzed. In the 6 × 6-mm ETDRS circle, VD (β coefficient = 0.37; 95% CI, 0.04-0.71; P = .03) and PFD (β coefficient = 0.009; 95% CI, 0.0003-0.018; P = .04) were lower in eyes of participants with PD. In the inner ring of the 6 × 6-mm ETDRS circle, VD (β coefficient = 0.61; 95% CI, 0.20-1.02; P = .003) and PFD (β coefficient = 0.015; 95% CI, 0.005-0.026; P = .004) were lower in eyes of participants with PD. Total choroidal area (β coefficient = -1.74 units2; 95% CI, -3.12 to -0.37 units2; P = .01) and luminal area (β coefficient = -1.02 units2; 95% CI, -1.86 to -0.18 units2; P = .02) were greater, but CVI was lower (β coefficient = 0.5%; 95% CI, 0.2%-0.8%; P < .001) in eyes of individuals with PD.

Conclusions and Relevance

This study found that individuals with PD had decreased retinal VD and PFD as well as choroidal structural changes compared with age- and sex-matched control participants. Given the observed population differences in these noninvasive retinal biomarkers, further research into their clinical utility in PD is needed.

Identifying Peripapillary Radial Capillary Plexus Alterations in Parkinson's Disease Using OCT Angiography

PURPOSE

To compare radial peripapillary capillary (RPC) plexus vascular parameters and retinal nerve fiber layer (RNFL) thickness between those with Parkinson's disease (PD) and controls.

DESIGN

Prospective, cross-sectional study.

PARTICIPANTS

A total of 151 eyes of 81 PD participants and 514 eyes of 266 controls.

METHODS

Participants underwent OCT angiography (OCTA) imaging using the Zeiss Cirrus HD-5000 AngioPlex (Carl Zeiss AG). Capillary perfusion density (CPD) and capillary flux index (CFI) were assessed using a 4.5 × 4.5-mm peripapillary scan, and RNFL thickness was assessed using a 200 × 200-μm optic nerve cube OCT scan. Hoehn and Yahr clinical staging for PD was determined by an experienced movement disorders specialist. Generalized estimating equations adjusted for age and sex were used for analysis.

MAIN OUTCOME MEASURES

Differences in RNFL thickness, CPD, and CFI as assessed using multivariable generalized estimating equations between individuals with PD and controls.

RESULTS

After adjustment for age and sex, average CPD (0.446% ± 0.018% vs. 0.439% ± 0.017%, P < 0.001) and CFI (0.434 ± 0.031 vs. 0.426 ± 0.036, P = 0.008) were significantly higher in PD eyes. Average RNFL thickness was similar between groups (PD 89.71 ± 10.45 μm vs. control 88.20 ± 10.33 μm, P = 0.19). Significant correlations between Hoehn and Yahr stage and OCTA parameters were not observed. The OCTA parameters were not significantly different between eyes of the same patient.

CONCLUSIONS

Increased peripapillary microvascular density and flux were detected in a large cohort of individuals with PD compared with controls after adjusting for age and sex; however, RNFL thickness was similar between groups. Peripapillary OCTA parameters may not correlate with the severity of PD. OCTA may serve as a noninvasive method to identify novel biomarkers for the early diagnosis of PD; as such, this methodology deserves further investigation.