Incidence, risk factors, and treatment of retroprosthetic membranes following Boston keratoprosthesis eyes and the impact of glaucoma surgery

PURPOSE

To assess incidence, risk factors, and treatment of retroprosthetic membrane (RPM) formation in eyes following Boston keratoprosthesis (Kpro) implantation and their correlation with glaucoma drainage device placement (GDD).

METHODS

A retrospective review was performed on eyes that underwent Kpro type I or II implantation between 2005 and 2020 at a tertiary academic center. Multiple variables were collected including preoperative characteristics, presence of RPM, management of RPM, and outcomes including corrected visual acuity (VA). A Fischer's exact test was used to evaluate the significance of risk factors of RPM formation and an odds ratio was calculated for each possible risk factor. A Mann-Whitney U test was used to evaluate comparisons between outcomes and qualitative analyses.

RESULTS

Of the 87 eyes identified, 37 (43%) developed an RPM within an average of 1.5 years (range, 31 days-7.5 years) following Kpro implantation. Mean follow-up duration was 4.3 years. Eyes that developed RPM had significantly worse preoperative VA compared to those that did not (logMAR 2.55 vs. 2.28, p = 0.022). The mean number of prior penetrating keratoplasty procedures trended higher in eyes that developed RPM (2.46 vs. 2.18, p = 0.44) but was not significant. GDD placement after Kpro implantation was associated with an increased risk of RPM formation (RR = 1.69 p = 0.026). Of the 37 eyes that developed an RPM following Kpro, 17 (47%) were treated with Nd:YAG laser, and four of those 17 (21%) also underwent pars plana vitrectomy (PPV). Seven of 37 eyes (19%) underwent PPV without Nd:YAG. Comparisons between RPM occurrence and final VA were not significant.

CONCLUSIONS

The incidence of RPM formation following Kpro implantation was 43%. Eyes that developed RPM had significantly worse preoperative VA. GDD placement after Kpro implantation increased the risk of developing RPM. Final VA and occurrence of RPM were not significantly different between the Nd:YAG and PPV treatment groups.

Longitudinal Retinal and Choroidal Image Analysis in a Set of Monozygotic Twins

We analyzed multimodal retinal and choroidal imaging, including optical coherence tomography (OCT) and OCT angiography (OCTA), to assess differences and characterize variations in the retinal and choroidal structure and microvasculature between healthy monozygotic twins without ocular or systemic pathology over a five-year period. Retinal imaging of both subjects revealed normal age-related changes. There was up to an 11% difference in OCT and OCTA variables within the subjects, both at baseline and at five years, and there was up to an 18% difference in OCT and OCTA parameters between the subjects for both time points. Larger changes in subfoveal choroidal thickness and foveal avascular zone area were observed. Our observations suggest that the parafoveal superficial capillary plexus, choroidal vascularity index, central subfield thickness, retinal nerve fiber layer thickness, and ganglion cell-inner plexiform layer thickness may be more heavily influenced by genetic, rather than environmental, factors. In contrast, subfoveal choroidal thickness and the foveal avascular zone area may be more heavily influenced by environmental factors. The environmental impact on retinal and choroidal structure and microvasculature is increasingly important to characterize, as such imaging parameters are being explored as potential biomarkers of systemic disease. These differences, as seen in these identical twin subjects, may be important considerations in supporting the security of biometric identifiers.

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.

IMPLICATIONS OF COMPLETE POSTERIOR VITREOUS DETACHMENT IN EYES WITH CENTRAL RETINAL VEIN OCCLUSION

BACKGROUND/PURPOSE

To evaluate the status of the posterior vitreous hyaloid on presenting optical coherence tomography images of the macula and its relationship to clinical characteristics, treatment patterns, and outcomes in eyes with central retinal vein occlusion.

METHODS

This is a retrospective longitudinal cohort study of consecutive patients with acute, treatment-naive central retinal vein occlusion diagnosed between 2009 and 2021 who had at least 12 months of follow-up. Clinical characteristics, treatment patterns, and outcomes were analyzed between eyes stratified based on the presence or absence of a complete posterior vitreous detachment (PVD) on optical coherence tomography at presentation.

RESULTS

Of 102 acute, treatment-naive central retinal vein occlusions identified, 52 (51%) had complete PVD at presentation and 50 (49%) did not. Central subfield thickness was significantly lower in those with complete PVD (12 months: 284.9 ± 122.9 µ m vs. 426.8 ± 286.4 µ m, P < 0.001; last follow-up: 278 ± 127.9 vs. 372.8 ± 191.0 µ m, P = 0.022). One-year intravitreal injection burden was significantly less for those with a complete PVD than those without (5.1 ± 3.6 injections vs. 6.7 ± 3.3 injections, P = 0.013).

CONCLUSION

Central retinal vein occlusion with complete PVD on presentation had significantly lower central subfield thickness and 1-year injection burden. Assessment of the vitreomacular interface in central retinal vein occlusion may serve as a prognostic imaging biomarker.

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.

Acute, Treatment-Naïve Branch Retinal Vein Occlusion in Younger Individuals: Risk Factors and Clinical Outcomes

Purpose: To compare the risk factors and clinical outcomes in patients younger than 50 years with acute, treatment-naïve branch retinal vein occlusion (BRVO) with outcomes in patients 50 years or older. Methods: Patients diagnosed with acute, treatment-naïve BRVO at Duke Eye Center over a 9.5-year period who had BRVO with onset 3 months or less before presentation, BRVO with macular involvement, and 12 months or more of follow-up were included. Demographic data, presenting clinical features, risk factors, treatment patterns, and clinical outcomes were extracted during a retrospective review of medical records. Results: Of 302 patients identified, 23 were younger than 50 years (younger group) and 279 were 50 years or older (older group). Compared with older patients, younger patients had similar rates of hypertension (P = .275), diabetes mellitus (P = 1.000), smokers (P = .787), and open-angle glaucoma (P = .628). The younger group had a lower rate of hyperlipidemia than the older group (35% vs 59%) (P = .028). The 2 groups had similar presenting logMAR visual acuities (VAs) in the BRVO eye (P = .131). At the final follow-up, younger patients had significantly better logMAR VA in the BRVO-affected eye than older patients (mean 0.51 ± 0.65 vs 1.01 ± 1.20) (P = .016). The 2 groups had similar treatment burdens at 1 year (P = .516) and at the final follow-up (P = .782). Conclusions: Younger patients with acute, treatment-naïve BRVO have similar risk factors and treatment patterns as older patients, except for a lower rate of hyperlipidemia. Younger patients with BRVO may have similar presenting VA as older BRVO patients but better final VA, suggesting that age may be a potential prognostic factor.

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.

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.

ENDOGENOUS ENDOPHTHALMITIS ASSOCIATED WITH INJECTION DRUG USE COMPARED WITH OTHER ETIOLOGIES

PURPOSE

To compare features of endogenous endophthalmitis associated with injection drug use (IDU) to endogenous endophthalmitis from other etiologies.

METHODS

The authors retrospectively collected data on patients with endogenous endophthalmitis due to IDU or other causes from three academic tertiary care centers over a six-year period. Differences in presenting characteristics, culture results, treatment, and visual acuity were compared between groups.

RESULTS

Thirty-eight patients (34%) had IDU-associated endogenous endophthalmitis while 75 patients (67%) had endogenous endophthalmitis from other causes. Compared with patients in the non-IDU group, IDU patients were significantly younger, more frequently male, had longer duration of symptoms at diagnosis, and were less likely to have bilateral disease ( P < 0.05 for all). Injection drug use patients were less likely to have a systemic infection source identified (29% vs. 71%, P < 0.001) or have positive cultures (47% vs. 80%, P < 0.001). The IDU group was less likely to be admitted to the hospital (71% vs. 92%, P = 0.005) and less likely to receive treatment with intravenous antimicrobials (55% vs. 83%, P = 0.003). Visual acuity did not significantly differ between groups.

CONCLUSION

Endophthalmitis related to IDU presents in younger patients with less comorbidities and frequently without positive cultures or an identifiable systemic source; therefore, a high index of suspicion is needed to identify this disease.

Asymmetric Purtscher-Like Retinopathy Caused by a Hypertensive Emergency and Undiagnosed Type 2 Diabetes

Purpose: To report a case of Purtscher-like retinopathy (PLR) in the setting of a hypertensive emergency and undiagnosed type 2 diabetes mellitus (DM). Methods: A case was analyzed. Results: A 29-year-old, obese, hypertensive man presented with a 10-day history of progressive vision loss in the left eye with no history of trauma. The visual acuity was 20/25 OD and hand motions OS. A fundus examination showed dilated, tortuous veins; dot-blot and flame hemorrhaging; numerous cotton-wool spots; and polygonal areas of retinal whitening consistent with Purtscher flecken in the right eye and a vitreous hemorrhage in the left eye. The blood pressure was 226/125 mm Hg, and the hemoglobin A1c was 11.6%. The patient's presentation was concerning for a hypertensive emergency and type 2 DM as the etiology for the ocular findings. Conclusions: The presence of one condition in association with PLR does not exclude the presence of another concurrent etiology.

Longitudinal Assessment of the Choroidal Vascularity Index in Eyes with Branch Retinal Vein Occlusion-Associated Cystoid Macular Edema

INTRODUCTION

Cystoid macular edema (CME) is the most common cause of central vision loss in eyes with branch retinal vein occlusion (BRVO eyes). In recent literature, choroidal vascularity index (CVI) has been proposed to be an enhanced depth imaging optical coherence tomography (EDI-OCT) metric that may help characterize choroidal vascular changes in the setting of retinal ischemia, and potentially prognose visual outcomes and treatment patterns for patients with BRVO-related CME. This study sought to further characterize choroidal vascular changes in BRVO by comparing the CVI, subfoveal choroidal thickness (SFCT), and central subfield thickness (CST) in BRVO eyes with CME compared to unaffected fellow eyes.

METHODS

This was a retrospective cohort study. Subjects included treatment-naïve BRVO eyes with CME diagnosed within 3 months of onset of symptoms and unaffected fellow eyes. EDI-OCT images were collected at baseline and at the 12-month follow-up visit. CVI, SFCT, and CST were measured. Demographics, treatment patterns, and best-corrected visual acuity (VA) were abstracted. Median CVI, SFCT, CST, and VA were compared between the two cohorts. Longitudinal relationships between these variables were analyzed.

RESULTS

A total of 52 treatment-naïve eyes with BRVO and CME and 48 unaffected fellow eyes were identified. Baseline CVI was lower in eyes with BRVO than in fellow eyes (64.7% vs. 66.4%, P = 0.003). At 12 months, there was no difference in CVI between BRVO eyes and fellow eyes (65.7% vs 65.8%, P = 0.536). In BRVO eyes, there was a strong correlation between reduced CST and improved VA over the 12-month study period (r = 0.671, P < 0.001).

CONCLUSION

There are differences in CVI in treatment-naïve BRVO eyes with CME at presentation compared to fellow eyes, but these differences resolve over time. Anatomic changes in macular thickness in BRVO eyes with CME may be correlated with VA outcomes.

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.

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.

Resident Vitreoretinal Procedure Volume: Effect of Intravitreal Injections, Region, Program Size, and Vitreoretinal Fellowship and Veterans Affairs Affiliation

Purpose  To analyze resident vitreoretinal procedure volume across Accreditation Council of Graduate Medical Education (ACGME) accredited ophthalmology residency programs. We assessed the effect of the increase in intravitreal injections (IVI), geographic region, program size, and Veterans Affairs (VA) and vitreoretinal fellowship affiliation on vitreoretinal procedures. Methods  A request was sent to all residency programs in 2018 for their graduating residents' ACGME case logs. Vitreoretinal procedures were defined by ACGME case log categories and included vitreoretinal surgery, peripheral retinal lasers, and IVI. Procedures were categorized by Current Procedural Terminology (CPT) code. Programs were studied by geographic region, program size, and by VA and vitreoretinal fellowship affiliation. Results  A total of 38 of 115 (33.0%) programs responded, and 167 residents logged 32,860 vitreoretinal procedures. The median number of retina procedures per resident was 146 (range 36-729). Programs with a vitreoretinal fellowship had a higher average number of vitreoretinal procedures per resident (208.3 vs. 125.0; p  = 0.002), but there was no difference between the average number of non-IVI vitreoretinal procedures (60.0 vs. 64.2; p  = 0.32). For IVI, VA affiliation (146.6 vs. 71.1; p  = 0.02) and vitreoretinal fellowship (149.4 vs. 60.8; p  < 0.001) were associated with a greater number. More IVI strongly correlated with a larger total volume of retinal procedures ( r  = 0.98), and there was no difference across programs for total retinal procedures when IVI was removed. Conclusions  The presence of a vitreoretinal fellowship at a residency program had a positive effect on resident total vitreoretinal case volume, but their residents performed more IVI. Programs without vitreoretinal fellowships completed on average more non-IVI procedures.

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.

Multimodal Imaging of West African Crystalline Maculopathy in an Igbo Man

PURPOSE

This report describes a case of West African crystalline maculopathy.

METHODS

A case report is presented.

RESULTS

A 71-year-old Nigerian man was referred for evaluation of bilateral crystalline retinal deposits seen on routine examination. The patient had no acute visual symptoms and no significant ocular history except for cataract extraction and intraocular lens implantation in both eyes. Dilated fundocscopic examination was notable for bilateral greenish-yellow, foveocentric intraretinal crystalline deposits, which were visible on color fundus photography, multicolor confocal scanning laser ophthalmoscopy, and spectral-domain optical coherance tomography. The crystalline deposits were not associated with abnormal short-wavelength autofluorescence or fluorescein angiography findings.

CONCLUSIONS

A diagnosis of West African crystalline maculopathy was made after other causes of crystalline maculopathy were excluded.

Management Patterns and Outcomes for Intravitreal Injection–Related Endophthalmitis

Purpose:

This work describes the clinical management and outcomes in cases of presumed infectious endophthalmitis following intravitreal injection at a tertiary academic medical center.

Methods:

A retrospective review took place of eyes that presented to the Duke Eye Center over a 9-year period and were diagnosed with intravitreal injection–related endophthalmitis. Clinical presentation, management, microbiologic yield, visual outcomes, and complications were abstracted from medical records.

Results:

Of 23 eyes diagnosed with postinjection endophthalmitis, 52.2% underwent anterior chamber tap (33.3% of which first underwent dry needle vitreous tap), 47.8% underwent needle vitreous tap, 17.4% underwent neither, and none underwent pars plana vitrectomy (PPV) for initial management. Subsequent PPV was performed in 6 eyes (26.1%). Mean visual acuity (VA) improved by 50 Early Treatment Diabetic Retinopathy Study letters at 6 months. Eyes that underwent initial anterior chamber tap had worse presenting VA than those that did not ( P = .01). Eyes undergoing subsequent PPV had worse VA at presentation ( P = .02) and at 6 months ( P < .001). Eyes presenting with VA of hand motion (20/8000) or worse were more likely to undergo subsequent PPV ( P = .02).

Conclusions:

Eyes with intravitreal injection–related endophthalmitis presenting with VA of hand motion or worse were more likely to undergo subsequent PPV. Future studies with larger cohorts may reveal whether earlier vitrectomy should be considered in these patients.

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.

Central Retinal Vein Occlusion: The Effect of Antiplatelet and Anticoagulant Agents

Purpose:

This work evaluates the effect of antiplatelet and anticoagulant agents on clinical outcomes, optical coherence tomography (OCT) parameters, and macular ischemia in eyes with central retinal vein occlusion (CRVO).

Methods:

A retrospective longitudinal cohort study was performed to evaluate patients with CRVO. Demographics, OCT parameters before and after treatment, macular ischemia on fluorescein angiography, and clinical outcomes including the number of injections received were analyzed.

Results:

A total of 365 patients with CRVO were identified. The average follow-up was 36 months. Antiplatelet or anticoagulant agent use was not associated with a significant difference in visual acuity (VA), prevalence of macular edema, or central subfield thickness on OCT at presentation or final visit. The use of 81-mg aspirin alone was associated with an increased prevalence of foveal hemorrhage at presentation. Patients who were taking an antiplatelet agent, an anticoagulation agent, or both and had an ischemic CRVO with logMAR VA of less than 1.0 experienced improved VA at the final study visit. Patients given antiplatelet or anticoagulant agents had a similar incidence of neovascular sequelae compared with patients not administered these agents.

Conclusions:

In eyes with CRVO, the use of antiplatelet or anticoagulant agents at CRVO onset was not associated with significantly different functional outcomes, except in ischemic CRVO eyes with VA of less than 20/200. The use of 81-mg aspirin was associated with foveal hemorrhage at CRVO presentation. Otherwise, the use of any antiplatelet agent or anticoagulation was not associated with any CRVO structural outcomes.

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.

The effect of select systemic medications on outcomes in diabetics with central retinal vein occlusion

BACKGROUND

Diabetes mellitus is a risk factor for central retinal vein occlusion (CRVO); however, it is unclear whether certain commonly used medications among diabetics or glycemic control impact visual outcomes in diabetic eyes with CRVO.

PURPOSE

To evaluate the effect of select systemic medications and glycemic control on presenting features, treatment burden, and outcomes in patients with diabetes who develop a central retinal vein occlusion (CRVO).

METHODS

Retrospective longitudinal cohort study at a single tertiary academic referral center from 2009-2017 investigating eyes of patients being treated for diabetes mellitus at CRVO onset. Eyes with a prior history of anti-vascular endothelial growth factor (anti-VEGF) therapy or laser treatment within the year prior to CRVO onset were excluded. Main outcomes and measures were visual acuity (VA), central subfield thickness (CST), cystoid macular edema (CME), and number of intravitreal injections and laser treatment throughout follow-up.

RESULTS

We identified 138 eyes of 138 participants who were diabetic at CRVO onset. Of these, 49% had an ischemic CRVO. Median follow-up time was 25.5 months. Fifty-five eyes (40%) had a HbA1c within 6 months of CRVO presentation. HbA1c was positively correlated with both presenting CST (p = 0.04) and presence of CME (p < 0.01). In all 138 eyes, mean presenting VA was 20/246, and mean final VA was 20/364. Better-presenting VA was significantly associated with aspirin 325 mg use (p = 0.04). Lower CST at presentation was significantly associated with metformin use (p = 0.02). Sitagliptin use at CRVO onset was associated with a lower prevalence of CME at final follow-up (p < 0.01). Lower final CST was significantly associated with glipizide use at CRVO onset (p = 0.01). There were no significant associations between systemic medications or HbA1c and treatment burden or final VA (p > 0.05).

CONCLUSION

Although aspirin 325 mg, metformin, sitagliptin, and glipizide were associated with better-presenting VA, lower-presenting CST, lower prevalence of macular edema at final visit, and lower final CST, respectively, none of these systemic agents or glycemic control were associated with decreased treatment burden or improved visual outcomes in diabetics with CRVO.

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.

Characteristics of Branch Retinal Vein Occlusion in African American Patients

BACKGROUND AND OBJECTIVES

To describe the presentation, management, and clinical outcomes of branch retinal vein occlusion (BRVO) in African American patients compared to patients of other racial or ethnic backgrounds.

PATIENTS AND METHODS

This retrospective cohort study included eyes diagnosed with BRVO and macular edema at a tertiary referral center. Presenting features, treatment, and outcomes were compared based on racial or ethnic backgrounds.

RESULTS

The study included 285 eyes: 21.8% African American, 78.2% other. African American patients were more likely to have comorbid diabetes (P = .012), open-angle glaucoma (P < .001), and to present with subretinal fluid (P = .049); multivariate analysis showed race and ethnicity alone may not fully explain presenting subretinal fluid (odds ratio = 2.807; 95% CI, 0.997 to 7.903; P = .051). There was no difference in other comparisons of clinical outcomes or treatment burden, including visual acuity, duration, or treatment method.

CONCLUSIONS

Despite significant differences at presentation, the management and outcomes of BRVO did not differ significantly between African American patients and patients of other racial and ethnic backgrounds. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:492-497.].

Systemic antiplatelet agents and anticoagulants in eyes with branch retinal vein occlusion

Purpose

The purpose of this study was to investigate the effect of systemic antiplatelet agents and anticoagulants on the structural and functional outcomes of eyes with branch retinal vein occlusion (BRVO).

Methods

A retrospective longitudinal cohort study was performed on BRVO patients evaluated at a single tertiary care referral center between 2009 and 2017. Medical records were reviewed for antiplatelet agent and anticoagulant use including aspirin, clopidogrel, warfarin, rivaroxaban, apixaban, or dabigatran prior to BRVO onset. In addition, optical coherence tomography (OCT) parameters, clinical outcomes, and treatment patterns were also recorded.

Results

A total of 354 BRVO eyes were identified with a mean follow-up time of 36 months. Antiplatelet or anticoagulant use was associated with presence of cystoid macular edema (CME) at presentation after controlling for potential confounding variables in a multivariate logistic regression. Multivariate regression also revealed an association between foveal hemorrhage at presentation and use of antiplatelet or anticoagulant medications. There were no significant differences in visual acuity or prevalence of CME at the final visit in those with antiplatelet/anticoagulant use compared to those not on these agents.

Conclusion

Although the use of systemic antiplatelet or anticoagulant agents was associated with increased prevalence of CME and foveal hemorrhage at presentation of BRVO, the use of these medications was not associated with different visual or structural outcomes at the final visit.

Treatment Patterns and Clinical Outcomes for Branch Retinal Vein Occlusion: An 8-Year Experience at a Tertiary Eye Center

Purpose:

This work aims to investigate real-world treatment patterns and outcomes in eyes with branch retinal vein occlusion in the antivascular endothelial growth factor (anti-VEGF) era.

Methods:

A retrospective, nonrandomized, comparative study was conducted on eyes diagnosed with branch retinal vein occlusion at a single tertiary center between 2009 and 2017. Medical history, treatment patterns, and visual acuity outcomes were examined. Subanalysis was performed for eyes that met the eligibility criteria for the BRAVO (Ranibizumab for the Treatment of Macular Edema Following Branch Retinal Vein Occlusion) trial.

Results:

A total of 315 eyes were included, of which 244 were treatment naive. In all eyes, the most common first treatment was the following: intravitreal bevacizumab (38.4%), aflibercept (15.1%), ranibizumab (8.1%), sectoral scatter laser (6.2%), and triamcinolone (3.1%). At 1 year, treatment-naive eyes had received an average of 2.43 anti-VEGF injections. During follow-up, treatment-naive eyes gained an average of 0.21 Early Treatment Diabetic Retinopathy Study lines. Forty eyes that met BRAVO trial criteria received an average of 5.05 anti-VEGF injections in the first year and gained an average of 1.83 Early Treatment Diabetic Retinopathy Study lines.

Conclusions:

This real-world cohort received fewer anti-VEGF injections at year 1 and experienced less improvement in visual acuity during the course of treatment than clinical trial participants. Trial-eligible patients received more injections and had greater visual gains than those who would not have been eligible for the trial.

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.].

Rhegmatogenous Retinal Detachment in the Setting of Endophthalmitis: Risk Factors and Visual Outcomes

BACKGROUND AND OBJECTIVE

To investigate risk factors for rhegmatogenous retinal detachment (RRD) and visual acuity (VA) in eyes with RRD after developing endophthalmitis.

PATIENTS AND METHODS

Retrospective comparative study of 133 eyes with endophthalmitis at a tertiary center between 2009 and 2018. Demographics, exam findings, interventions, and outcomes were assessed. Cases of RRD within 6 months after onset of endophthalmitis were further analyzed.

RESULTS

Seventeen eyes (12.7%) with endophthalmitis developed RRD. Endogenous etiology was associated with higher rate of RRD (P = .038). Eyes that developed RRD had worse VA (20/3271) at 6 months (20/236; P = .001). Excluding the six eyes with macula-off RRD, VA for the remaining 11 eyes that developed RRD (20/1213) was similar to those without RRD (20/236; P = .095).

CONCLUSIONS

Endogenous etiology of endophthalmitis was associated with a higher rate of RRD. Eyes with successful RRD repair had outcomes similar to eyes that did not develop RRD. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:257-262.].

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.

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.

The application of optical coherence tomography angiography in Alzheimer's disease: A systematic review

INTRODUCTION

Discovering non-invasive and easily acquired biomarkers that are conducive to the accurate diagnosis of dementia is an urgent area of ongoing clinical research. One promising approach is retinal imaging, as there is homology between retinal and cerebral vasculature. Recently, optical coherence tomography angiography (OCT-A) has emerged as a promising new technology for imaging the microvasculature of the retina.

METHODS

A systematic review and meta-analysis was conducted to examine the application of OCT-A in dementia.

RESULTS

Fourteen studies assessing OCT-A in preclinical Alzheimer's disease (AD), mild cognitive impairment, or AD were included. Exploratory meta-analyses revealed a significant increase in the foveal avascular zone area and a significant decrease in superficial parafoveal and whole vessel density in AD, although there was significant heterogeneity between studies.

DISCUSSION

Although certain OCT-A metrics may have the potential to serve as biomarkers for AD, the field requires further standardization to allow conclusions to be reached regarding their clinical utility.

Choroidal Structural Analysis in Alzheimer Disease, Mild Cognitive Impairment, and Cognitively Healthy Controls

PURPOSE

To assess choroidal structural parameters in symptomatic Alzheimer disease (AD), mild cognitive impairment (MCI), and cognitively healthy control subjects.

DESIGN

Prospective cross-sectional study.

METHODS

This study took place in an outpatient neurological disorders clinic. Participants included 67 patients (112 eyes) with AD, 74 patients (143 eyes) with MCI, and 137 (248 eyes) control subjects. Subjects with diabetes, glaucoma, or retinal pathology were excluded. High-definition enhanced depth imaging foveal scans were obtained using Zeiss Cirrus HD-5000 AngioPlex. Subfoveal choroidal thickness (SFCT) was measured by 2 masked graders with a third adjudicator. Total choroidal area (TCA), luminal area (LA), and the choroidal vascularity index (CVI) were calculated after image binarization. Association of choroidal parameters with AD, MCI, or control subjects was assessed using multivariable generalized estimating equations, adjusted for age, sex, and visual acuity.

RESULTS

After adjustment for age, sex, and visual acuity, TCA was significantly greater in patients with AD (ß = 2.73; p = .001) and MCI (ß = 4.38; p < .001) compared with control subjects. LA was significantly greater in patients with AD (ß = 1.68; p = .001) and MCI (ß = 2.69; p < .001) compared with control subjects, and CVI was significantly lower in patients with MCI (ß = -0.58; p = .002) compared with control subjects. SFCT was similar among patients with AD and MCI and control subjects on multivariable analysis (p > .05).

CONCLUSIONS

TCA, LA, and CVI may differ between patients with AD, MCI, and healthy cognition, whereas SFCT may not differ among these groups. TCA, LA, and CVI deserve further study in subjects on the Alzheimer continuum.

Ocular Toxocariasis Presenting as Endophthalmitis in a Young Adult Intravenous Drug User

Purpose:

This report describes the diagnosis of ocular toxocariasis presenting as endophthalmitis in an adult intravenous drug user.

Methods:

A case is reported.

Results:

Fundus imaging showed numerous white opacities obscuring the macula. Toxocara canis serology was reactive with an enzyme immunoassay titer of 1:2 (positive ≥ 1:32). Findings from bacterial and fungal cultures were negative, and vitrectomy cytology revealed no organisms. Postoperatively, serial optical coherence tomography imaging demonstrated a slight decrease in size of an intraretinal hyperreflective lesion in the macula.

Conclusions:

Owing to a variety of presentations, ocular toxocariasis can be challenging to diagnose. In a patient with a history of intravenous drug use where fungal and bacterial organisms are more common causes of endophthalmitis, it is important to have a wide differential of causative organisms, particularly in the context of negative culture results and a worsening clinical examination.

Treatment Patterns and Outcomes in Bleb-Related Endophthalmitis: A 9-Year Analysis at a Tertiary Eye Center

Purpose:

Clinical presentation, treatment choices, and outcomes in cases of bleb-related endophthalmitis (BRE) at a tertiary care center over a 9-year period are described.

Methods:

A retrospective review was conducted of patients diagnosed with BRE at Duke Eye Center (Durham, North Carolina) from January 1, 2009 to January 1, 2018, with at least 6 months of follow-up, assessing demographic data, initial management, and visual acuity (VA).

Results:

Twenty eyes of 20 patients with BRE were identified. Median time from surgery to presentation was 6.53 years. Presenting VA of light perception only was significantly associated with the decision to pursue pars plana vitrectomy (PPV) as initial treatment (odds ratio 59.4, 95% CI, 2.1-1670.8, P = .016). Twelve eyes (60%) had culture-proven infectious endophthalmitis. Eleven eyes (55%) underwent PPV during treatment; 5 eyes underwent PPV on presentation, and 6 eyes underwent PPV after initial presentation. Compared with pre-endophthalmitis VA, 6 eyes that underwent subsequent PPV had greater VA loss at 6 months than cases not undergoing subsequent PPV (Early Treatment Diabetic Retinopathy Study line loss of 14 vs 4 lines, respectively; P = .044).

Conclusions:

BRE eyes presenting with light-perception VA were more likely to undergo initial PPV; yet many eyes in this study required PPV during treatment. Visual outcomes are often poor in BRE despite intensive management. There was greater VA loss from pre-endophthalmitis VA levels at 6 months in eyes undergoing PPV after initial treatment. Prospective studies are needed to assess the optimal role of PPV in patients with BRE.

Endophthalmitis After Descemet Stripping Endothelial Keratoplasty: Microbiological Yield and Visual Outcomes

PURPOSE

To describe the clinical presentation, management, and visual outcomes of 6 eyes with endophthalmitis after Descemet stripping endothelial keratoplasty (DSEK).

DESIGN

Retrospective case series.

METHODS

Setting: Tertiary, academic eye center. StudyPopulation: Individuals developing endophthalmitis after DSEK at the Duke Eye Center from January 1, 2009, to January 1, 2018, with at least 6 months of follow-up. ObservationProcedure: Retrospective chart review. OutcomeMeasures: Diagnostic procedures, microbiological yield, and visual outcomes.

RESULTS

Six eyes of 6 patients were identified. Mean time from surgery to presentation was 51 days (range, 4-137 days). Dense vitreous opacities were present in all cases. Five of 6 cases (83%) had culture-proven infectious endophthalmitis (2 Candida glabrata, 2 coagulase-negative Staphylococcus, 1 Streptococcus pneumoniae). Aqueous tap yielded positive culture in 2 of 2 cases with adequate sample (100%); needle vitreous tap yielded positive culture in 0 of 3 cases. One eye underwent vitrectomy on presentation, and 3 eyes (50%) underwent subsequent vitrectomy for persistent endophthalmitis after a mean of 37 days. Mean pre-endophthalmitis visual acuity (VA) was 20/64; mean VA at 6 months was 20/2069 (average 15 ETDRS lines lost). VA at 6 months was light perception or no light perception in 3 of 6 cases (50%). One eye underwent enucleation at 6 months, and 1 eye became phthisical 1 year after endophthalmitis.

CONCLUSIONS

DSEK-related endophthalmitis may lead to severe vision loss, even with prompt and appropriate treatment. Aqueous tap had a higher culture yield than needle vitreous tap in our series.

Choroidal vascularity index: a step towards software as a medical device

The choroidal vascularity index (CVI) is a relatively new parameter, calculated off optical coherence tomography (OCT) images, for the quantitative evaluation of choroid vascularity. It is defined as the ratio of vascular area to the total choroidal area, presented as a percentage. The choroid is an important vascular bed, often implicated in ocular and systemic conditions. Since the introduction of CVI, multiple studies have evaluated its efficacy as a tool for disease prognostication and monitoring progression, with promising results. The CVI was born out of the need for more robust and accurate evaluations of choroidal vasculature, as prior parameters such as choroidal thickness and choroidal vessel diameter had their limitations. In this review, we summarise current literature on the CVI, explain how the CVI is derived and explore its potential integration into future research and translation into clinical care. This includes the application of CVI in various disease states, and ongoing attempts to produce an automated algorithm which can calculate CVI from OCT images.

Initial Presentation of Cutibacterium (Formerly Propionibacterium) acnes Endophthalmitis Twenty-One Years After Cataract Surgery

The authors report a case of an 81-year-old female who presented with sudden onset of light perception vision and intraocular inflammation. After several months of continuing symptoms despite antibiotics, an aqueous tap culture grew Cutibacterium acnes. The patient had cataract surgery 21 years prior, and had no intervening trauma, intraocular procedure, or endogenous source. The presumed diagnosis was C. acnes endophthalmitis with significantly delayed onset. Capsulectomy and intraocular lens removal resolved the patient's symptoms. In rare cases, C. acnes endophthalmitis may present as recurrent inflammation despite an extremely remote history of cataract surgery, mimicking a virulent, acute-onset endophthalmitis despite antibiotic administration. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:44-46.].