Acute Bilateral Descemet Membrane Endothelial Keratoplasty Graft Rejection After the BNT162b2 mRNA COVID-19 Vaccine.

Purpose: We report a case of acute bilateral Descemet membrane endothelial keratoplasty (DMEK) rejection two weeks following BNT162b2 mRNA COVID-19 vaccine (Pfizer-BioNTech), reflecting on possible changes to the management of patients with DMEK scheduled for COVID-19 vaccination. Patients and Methods: A 94-year-old woman with Fuchs' endothelial dystrophy who underwent DMEK 24 months earlier (right eye) and 20 months earlier (left eye) demonstrated bilateral graft rejection two weeks after the first dose of COVID-19 vaccine. Standard treatment regimen was followed, and clinical status documented with slit-lamp examination and swept-source optical coherence tomography throughout. Results: Preoperative best corrected visual acuity (BCVA) and corneal thickness (CT) were 0.3 and 679µm right eye and 0.2 and 668µm left eye. Postoperative BCVA and CT were 0.7 and 559µm right eye and 0.4 and 590µm left eye. Standard treatment regimen consisted of dexamethasone/tobramycin and ketorolac, four times daily. At one month, both preparations were discontinued, replaced by dexamethasone 0.1% four times daily. At three months, this was tapered to once daily. Post-rejection, BCVA and CT were 0.2 and 710µm right eye and 0.3 and 710µm left eye. Treatment was with dexamethasone/tobramycin six times daily. Poor response resulted in re-DMEK transplantation, starting in the left eye. At one-month follow-up, BCVA and CT were 0.5 and 538µm right eye and 0.63 and 504µm left eye. Conclusion: We report the first acute bilateral DMEK graft rejection after a single dose of COVID-19 vaccine. We recommend clinicians exercise vigilance and consider dexamethasone 0.1% during the vaccination period.

Full-Field Electroretinography Changes Associated with Age-Related Macular Degeneration: A Systematic Review with Meta-Analyses.

BACKGROUND: The aim of this study was to systematically review the literature and to perform meta-analyses on full-field electroretinography (ffERG) between healthy controls and age-related macular degeneration (AMD) to map the extent of retinal dysfunction. SUMMARY: We systematically searched 11 databases on 3 March 2021. Eligible studies had to measure retinal function using ffERG in eyes with AMD and in healthy controls. We extracted data on a-wave and b-wave function in dark- and light-adapted ffERG and calculated summary estimates on differences between eyes with AMD and controls using weighted mean differences (WMD). Subgroup analyses were made for early and late AMD. Six studies (n = 481 eyes) were eligible for review (301 with any AMD, 180 controls). For dark-adapted data, any AMD was associated with reduced a-wave amplitude (WMD: -17.16 µV; 95% CI: -31.79 to -2.52 µV; p = 0.02) and b-wave amplitude (WMD: -28.70 µV; 95% CI: -51.40 to -6.01 µV; p = 0.01). For light-adapted data, any AMD was associated with longer a-wave implicit time (WMD: 0.92 ms; 95% CI: 0.12-1.72 ms; p = 0.02), reduced b-wave amplitude (WMD: -13.26 µV; 95% CI: -18.64 to -7.88 µV; p < 0.0001), and longer b-wave implicit time (WMD: 0.69 ms; 95% CI: 0.30-1.08 ms; p = 0.0006). Subgroup analyses found that these changes were only statistically significant in eyes with late AMD, not early AMD. KEY MESSAGES: Reduced retinal function on ffERG is present in eyes with AMD, in particular those with late AMD. These findings suggest that AMD is a pan-retinal disease with AMD-associated photoreceptor dysfunction beyond the macula.

Correlation of macular sensitivity measures and visual acuity to vision-related quality of life in patients with age-related macular degeneration.

BACKGROUND: Visual acuity is commonly used as a functional outcome measure in patients with age-related macular degeneration (AMD), despite having a weak correlation with self-perceived visual quality of life. Microperimetry is a useful method of detecting loss of macular function. We wanted to investigate the relationship between these two objective visual outcome measures and subjective vision-related quality of life, finding out which objective measure is more patient-relevant. METHODS: Fifty-one consecutive patients with AMD were recruited to the study. Participants were required to complete the Visual Function Questionnaire 39, the Early Treatment Diabetic Retinopathy Study visual acuity examination and a microperimetry assessment using the Micro Perimeter 3. One patient withdrew consent and seven patients dropped out due to cooperation difficulties under microperimetry. Forty-three patients with AMD were included in the study: twenty-eight patients with late AMD (exudative AMD) and fifteen patients with early (non-exudative) AMD. The right eye was included as standard, as was the eye with the best-corrected visual acuity. RESULTS: There was a higher correlation between vision-related quality of life and macular sensitivity (r = 0.458; p = 0.014) than between vision-related quality of life and visual acuity (r = 0.446; p = 0.018) in patients with late AMD. There was a positive correlation between vision-related quality of life and macular sensitivity in patients with early AMD (r = 0.542; p = 0.037) while the correlation between vision-related quality of life and visual acuity in these patients was not statistically significant. Composite score (r = 0.469; p = 0.012) correlated highest with the nasal outer macular sub-region and near-distance activities score (r = 0.652; p < 0.001) correlated highest with the nasal inner macular sub-region in patients with late AMD. Correlations between composite score and macular sub-regions in patients with early AMD were not significant, but near-distance activities score correlated with the nasal outer macular sub-region in these patients (r = 0.469; p = 0.012). CONCLUSIONS: Macular sensitivity as measured using microperimetry correlates with vision-related quality of life in early AMD and in late AMD, showing it to be a patient-relevant outcome measure. Furthermore, the nasal sub-regions of the macula appear to be preferred retinal loci in patients with AMD. (338 words).

Full-field electroretinography in age-related macular degeneration: an overall retinal response.

PURPOSE: Age-related macular degeneration (AMD) is generally considered a disease of the macula. However, recent studies show peripheral retinal lesions are prevalent in patients with AMD, indicative of a disease process that is more widespread. Full-field electroretinography (ffERG) measures an electrical response, not only from the macula, but from the entire retina. We wanted to study the ffERG response in eyes with AMD. METHODS: We performed full-field electroretinography (RETI-port/scan 21, Roland, Berlin) in 13 patients with early AMD, 25 patients with late AMD and 24 individuals without vitreoretinal disease as a control group. Dawson-Trick-Litzkow fibre electrodes were used. Statistical analysis was performed and a p-value <0.05 was considered significant. RESULTS: After adjusting for multiple comparisons, both the light-adapted 3.0 a-wave implicit time (p < 0.001) and 30-Hertz flicker peak time (p = 0.012) showed significant difference between patients with late AMD and individuals without vitreoretinal disease. There was a significant difference in the light-adapted 3.0 a-wave implicit time (p = 0.011) between patients with early AMD and the control group, but the difference in 30 Hz flicker peak time was not significant (p = 0.256). CONCLUSION: The difference in cone function measured by light-adapted 3.0 a-wave implicit time and 30-Hertz flicker peak time in early and late AMD when compared to healthy controls suggests a more diminished overall response when AMD has reached later stages.

Full-field Electroretinography in Age-related Macular Degeneration: can retinal electrophysiology predict the subjective visual outcome of cataract surgery?

PURPOSE: Predicting the visual gain from cataract surgery when the main cause of vision loss is age-related macular degeneration may be difficult and warrants the need for an objective predictor of subjective outcome. Full-field electroretinography is an objective measure of overall retinal function. We therefore wanted to study if full-field electroretinography can predict subjective visual outcome using visual function questionnaire. METHODS: Thirty-one patients with age-related macular degeneration operated for bilateral cataract underwent full-field electroretinography preoperatively. Full-field electroretinography was performed according to International Society for the Clinical Electrophysiology of Vision standards using a Ganzfeld bowl (RETI-port/scan 21, Roland, Berlin) and Dawson-Trick-Litzkow fibre electrodes. Vision-related quality of life was measured using the National Eye Institute Visual Function Questionnaire-39 before first-eye surgery and 4.12 ± 2.11 months after second-eye surgery. RESULTS: Mean change in composite visual function questionnaire score after cataract surgery was 9.2 ± 11.9. The patients were divided into three groups: visual function questionnaire composite score increase >10 (n = 17); no change (n = 8); and decrease (n = 6). In the dark-adapted full-field electroretinography responses, we found a significant difference between the three groups in the 0.01 b-wave amplitude (p = 0.05), the 10.0 b-wave amplitude (p = 0.04) and a near-significant difference in 3.0 a-wave amplitude (p = 0.09). Other dark-adapted responses (the 3.0 b-wave and 10.0 a-wave) did not show any significant differences between the three groups, and neither did the light-adapted responses. CONCLUSION: Patients with low dark-adapted responses on full-field electroretinography preoperatively experience a decrease in subjective vision-related quality of life, suggesting that maintained rod function before cataract surgery may be important.

Peripheral Retinal Lesions in Eyes with Age-Related Macular Degeneration Using Ultra-Widefield Imaging: A Systematic Review with Meta-analyses.

TOPIC: Age-related macular degeneration (AMD) is highly prevalent among the elderly. We systematically reviewed the literature to provide an overview of ultra-widefield imaging (UWFI) of peripheral retinal lesions in AMD. CLINICAL RELEVANCE: Information regarding retinal characteristics and prevalence of AMD is based mainly on studies using color photography of the central retina, where early and potentially severe manifestations of the disease are found. However, this approach has the effect of neglecting the periphery. Studies using UWFI provide new evidence to show that clinical features associated with AMD are not exclusive to the area of the macula. METHODS: Eligible studies had to detect lesions of the peripheral retina (based on the original definition of a standard macular grid, with the addition of 2 zones classed as peripheral) using UWFI in eyes with AMD. Ultra-widefield imaging included pseudocolor photography, fundus autofluorescence, fluorescein angiography, and indocyanine green angiography. Eligibility was restricted to human participants and studies written in English. We searched the bibliographic databases PubMed, the Cochrane Library, EMBASE, and the Web of Science on March 27, 2018. We calculated the prevalence of peripheral findings in eyes with AMD and performed similar meta-analyses on the healthy control group. A random-effects model was used because of possible study heterogeneity. RESULTS: Twelve studies were eligible for the review, which included 3261 or more eyes. Studies were clinic based, apart from 1 study that was a random population sample of individuals 62 years of age or older. Studies were cross-sectional in nature, apart from 1 case-control study. The peripheral lesions most commonly observed were drusen, atrophy, and changes to the retinal pigment epithelium. In eyes with AMD, peripheral lesions were found in 82.7% of eyes (confidence interval, 78.4%-86.7%) compared with 33.3% of healthy eyes (confidence interval, 28.3%-38.5%). CONCLUSIONS: Peripheral changes were found to be highly prevalent in eyes with AMD, supporting the claim that the disease is panretinal and not macula only. The clinical significance of peripheral lesions in AMD remains incompletely understood, and therefore, further UWFI studies are recommended.

[Christmas article: Christmas-related exogenous palmar hyperpigmentation].

On a routine control for macular degeneration, a 90-year-old man presented with hyperpigmentation of the skin on both palms and bilateral thumbnail discolouration. He was otherwise asymptomatic. He had been shelling walnuts to store in his freezer for use as Christmas cake decorations. Shortly after, he noticed the cutaneous colour change in both palms. The condition resolved spontaneously over a period of about three weeks. Outbreaks of walnut shell-related hyperpigmentation tend to occur during the cake decorating season, especially at Christmas time, and often present with so-called "cake decorators' palms".