Central Retinal Artery Occlusion with Concomitant Intracranial Hemorrhage Secondary to Streptococcus Gordonii Endocarditis.

Purpose: To report a case of central retinal artery occlusion (CRAO) associated with subacute Streptococcus gordonii endocarditis secondary to a dental infection. Observations. A 27-year-old male presented with acute monocular vision loss in the setting of a stroke and seizure. A fundus exam revealed macular whitening and a cherry-red spot. Edema of the inner retinal layers was confirmed on macular optical coherence tomography, consistent with CRAO. Initial imaging (carotid Doppler, EKG, and transthoracic echocardiography) and a comprehensive laboratory workup did not reveal an etiology for the stroke or vision loss. Brain magnetic resonance imaging showed T1 hyperintensity with surrounding edema, which prompted a workup for possible septic emboli versus occult malignancy. Subsequent blood cultures led to the detection and diagnosis of Streptococcus gordonii endocarditis. It was subsequently revealed that the patient had self-extracted his molar two months prior to the onset of symptoms. Conclusions: Endocarditis has been associated with Roth spots and inflammatory findings in the posterior segment. However, CRAO caused by vegetal septic embolism is rare. To our knowledge, this represents the first reported case of endocarditic CRAO with Streptococcus gordonii confirmed as the causative microbe. Retinal vascular occlusion in a young patient with no distinct risk factors should prompt a comprehensive dental history and infectious workup, with consideration given to early transesophageal echocardiography.

Economic Evaluation of Artificial Intelligence Systems Versus Manual Screening for Diabetic Retinopathy in the United States.

BACKGROUND: The objective of this economic modeling study was to compare the cost effectiveness of fully automated retinal image screening (FARIS) to the current practice of universal ophthalmologist referral for diabetic retinopathy in the United States (US) health care system. METHODS: A Markov decision-analytic model was used to compare the automated versus manual screening and management pathway for diabetic patients with unknown retinopathy status. Costs (in 2021 US dollars), quality-adjusted life year (QALY) gains, and incremental cost-effectiveness ratios were calculated. Sensitivity analysis was performed against a $50,000/QALY willingness-to-pay threshold. RESULTS: FARIS was the dominant screening strategy, demonstrating cost savings of 18.8% at 5 years with equivalent net QALY gains to manual screening. Cost-effectiveness status was dependent on FARIS detection specificity, with a threshold value of 54.8%. CONCLUSION: Artificial intelligence-based screening represents an economically advantageous screening modality for diabetic retinopathy in the US, offering equivalent long-term utility with significant potential cost savings. [Ophthalmic Surg Lasers Imaging Retina 2023;54:272-280.].

Association Between Parental Leave and Ophthalmology Resident Physician Performance.

Importance: Although parental leave is essential in enhancing resident wellness and fostering inclusive workplace environments, residents may often feel discouraged from using parental leave owing to perceived stigma and concerns about possible negative effects on their training. Objective: To examine parental leave usage across multiple institutions and compare residency performance metrics between residents who took parental leave vs their peers who did not take leave. Design, Setting, and Participants: This was a retrospective cross-sectional analysis conducted from April 1, 2020, to July 28, 2022, of educational records. Multicenter data were obtained from 10 Accreditation Council for Graduate Medical Education (ACGME)-accredited ophthalmology programs across the US. Included ophthalmology residents graduated between 2015 and 2019. Data were analyzed from August 15, 2021, to July 25, 2022. Exposures: Performance metrics of residents who used parental leave during residency were compared with those of residents who did not take parental leave. Main Outcomes and Measures: Measures of performance included the Ophthalmic Knowledge Assessment Program (OKAP) scores, ACGME milestones scores, board examination pass rates, research activity, and surgical volumes. Results: Of the 283 ophthalmology residents (149 male [52.7%]) included in the study, 44 (15.5%) took a median (IQR) parental leave of 4.5 (2-6) weeks. There were no differences in average OKAP percentiles, research activity, average ACGME milestones scores, or surgical volume between residents who took parental leave and those who did not. Residents who pursued fellowship were less likely to have taken parental leave (odds ratio [OR], 0.43; 95% CI, 0.27-0.68; P < .001), and residents who practiced in private settings after residency were more likely to have taken parental leave (OR, 3.56; 95% CI, 1.79-7.08; P < .001). When stratified by sex, no differences were identified in performance between female residents who took parental leave compared with residents who did not take leave, except a mild surgical number difference in 1 subspecialty category of keratorefractive procedures (difference in median values, -2; 95% CI, -3.7 to -0.3; P = .03). Conclusions and Relevance: In this multicenter cross-sectional study, no differences in performance metrics were identified between residents taking parental leave compared with their peers. These findings may provide reassurance to trainees and program directors regarding the unlikelihood, on average, that taking adequate parental leave will affect performance metrics adversely.

Gender Differences in Case Volume Among Ophthalmology Residents.

IMPORTANCE: Although almost equal numbers of male and female medical students enter into ophthalmology residency programs, whether they have similar surgical experiences during training is unclear. OBJECTIVE: To determine differences for cataract surgery and total procedural volume between male and female residents during ophthalmology residency. DESIGN, SETTING, PARTICIPANTS: This retrospective, longitudinal analysis of resident case logs from 24 US ophthalmology residency programs spanned July 2005 to June 2017. A total of 1271 residents were included. Data were analyzed from August 12, 2017, through April 4, 2018. MAIN OUTCOMES AND MEASURES: Variables analyzed included mean volumes of cataract surgery and total procedures, resident gender, and maternity or paternity leave status. RESULTS: Among the 1271 residents included in the analysis (815 men [64.1%]), being female was associated with performing fewer cataract operations and total procedures. Male residents performed a mean (SD) of 176.7 (66.2) cataract operations, and female residents performed a mean (SD) of 161.7 (56.2) (mean difference, -15.0 [95% CI, -22.2 to -7.8]; P < .001); men performed a mean (SD) of 509.4 (208.6) total procedures and women performed a mean (SD) of 451.3 (158.8) (mean difference, -58.1 [95% CI, -80.2 to -36.0]; P < .001). Eighty-five of 815 male residents (10.4%) and 71 of 456 female residents (15.6%) took parental leave. Male residents who took paternity leave performed a mean of 27.5 (95% CI, 13.3 to 41.6; P < .001) more cataract operations compared with men who did not take leave, but female residents who took maternity leave performed similar numbers of operations as women who did not take leave (mean difference, -2.0 [95% CI, -18.0 to 14.0]; P = .81). From 2005 to 2017, each additional year was associated with a 5.5 (95% CI, 4.4 to 6.7; P < .001) increase in cataract volume and 24.4 (95% CI, 20.9 to 27.8; P < .001) increase in total procedural volume. This increase was not different between genders for cataract procedure volume (ß = -1.6 [95% CI, -3.7 to 0.4]; P = .11) but was different for total procedural volume such that the increase in total procedural volume over time for men was greater than that for women (ß = -8.0 [95% CI, -14.0 to -2.1]; P = .008). CONCLUSIONS AND RELEVANCE: Female residents performed 7.8 to 22.2 fewer cataract operations and 36.0 to 80.2 fewer total procedures compared with their male counterparts from 2005 to 2017, a finding that warrants further exploration to ensure that residents have equivalent surgical training experiences during residency regardless of gender. However, this study included a limited number of programs (24 of 119 [20.2%]). Future research including all ophthalmology residency programs may minimize the selection bias issues present in this study.

Dynamic indocyanine green angiography-guided focal thermal laser treatment of fibrotic choroidal neovascularization.

PURPOSE: Fibrotic choroidal neovascular membranes (CNV) are the end-stage outcomes of neovascular age-related macular degeneration (AMD). No treatment is currently available for fibrotic CNV. We investigated the role of focal thermal laser ablation of the perfusing afferent arteriole as determined by dynamic indocyanine green angiography (ICGA). METHODS: We conducted a retrospective study of 20 patients with fibrotic CNV associated with significant subretinal fluid or retinal edema, who also demonstrated well-defined perfusing arterioles by dynamic ICGA. Patients underwent focal thermal laser occlusion of the perfusing afferent arteriole. Six, 12 and 24 weeks post-treatment, eyes underwent repeat examination with optical coherence tomography (OCT) and visual acuity testing, and ICGA at 12 weeks. RESULTS: Therapeutic closure of the perfusing afferent arterioles was achieved in 17 of 20 eyes immediately post-treatment. All 17 of these eyes demonstrated significant resolution of retinal edema and subretinal fluid, as evidenced by OCT, which was dramatic in some cases. Seven eyes demonstrated an improvement in visual acuity of 1 line or more. While most eyes demonstrated reperfusion within 3 months, many lesions suggested reduced vascularity and flow. CONCLUSION: Eyes with fibrotic CNV and associated retinal edema often demonstrate well-defined vascularity of the fibrosis with discrete perfusing arterioles when imaged by dynamic ICGA. Thermal laser occlusion of these arterioles can result in resolution of subretinal fluid, and occasionally an improvement in vision. This represents a potential therapeutic intervention for an advanced stage of AMD currently regarded as stable.

PEDF Promotes Biosynthesis of a Novel Anti-inflammatory and Anti-apoptotic Mediator NPD1 in Retinal Pigment Epithelial Cells.

PURPOSE: Neuroprotectin D1 is a stereospecific cytoprotective messenger synthesized from docosahexaenoic acid in retinal pigment epithelial cells challenged by oxidative stress. A key step in neuroprotectin D1 synthesis is to define how growth factors may modulate its formation and its bioavailability. Here we have explored the action of pigment epithelium derived factor, a neurotrophin made in retinal pigment epithelial cells, on neuroprotectin D1. METHODS: ARPE-19 cells were serum starved and exposed to TNFα/H(2)O(2) in the presence and absence of pigment epithelium derived factor (10 mg/mL). Cells and incubation media were collected. LC-PDA-MS-MS-based lipidomic analysis was used to identify and quantitate neuroprotectin D1. Immunostaining for BCLxL was performed. RESULTS: Oxidative stress promotes increases in neuroprotectin D1 levels in ARPE-19 cells, showing a rapid increase up to 6 hrs of incubation of 12 folds measured on cell pellets. Cell media, on the other hand, show time dependent accumulation of neuroprotectin D1 up to 55-fold after 12 hrs incubation. Treatment with 50 nM pigment epithelium derived factor increased such profile by at least two fold. Deuterated docosahexaenoic acid was incorporated to cell membranes and converted into neuroprotectin D1. After cells are exposed to oxidative stress, BCLxL appears to shift to the nucleus of the cell. With the addition of pigment epithelium derived factor and docosahexaenoic acid, this translocation seems to be prevented. CONCLUSIONS: Here we demonstrate that pigment epithelium derived factor is an activator of neuroprotectin D1 synthesis in ARPE-19 cells exposed to oxidative stress. A major action of pigment epithelium derived factor-stimulated neuroprotectin D1 synthesis shown here is retinal pigment epithelial cytoprotection. Since the retinal pigment epithelial cell is impaired in retinal degeneration, these novel mechanisms potentially may be targeted in macular degeneration and other retinal degenerative diseases as a new therapeutic avenue and may be applicable for neuroprotection in glaucoma and in other neurodegenerative diseases.

Quantitative enumeration of vascular smooth muscle cells and endothelial cells derived from bone marrow precursors in experimental choroidal neovascularization.

Choroidal neovascularization (CNV) is characterized by the subretinal invasion of a pathologic new vessel complex from the choriocapillaris. Although CNV is traditionally considered to consist of endothelial cells, the cellular population of CNV is likely more complex in nature, comprising several different cell types. In addition, recent studies suggest that the CNV cell population has a dual origin (circulating versus resident populations). In this study we sought to determine the contribution and origin of different cell types in experimental CNV. Laser-induced CNV was performed on chimeric mice generated by reconstituting C57BL/6 mice with bone marrow from green fluorescent protein (GFP)-transgenic mice. In these mice, bone marrow-derived cells are GFP-labeled. Immunofluorescence staining was used to examine both flatmount preparations of the choroid and cross sections of the posterior pole for macrophages, endothelial cells, vascular smooth muscle cells, retinal pigment epithelial (RPE) cells, lymphocytes, or neutrophils at day 3, 7, 14 and 28 post-laser (n=5 per group). Cell types present in CNV included macrophages (20% of the cells in CNV), endothelial cells (25%), vascular smooth muscle cells (11%), RPE cells (12%) and non-labeled cells (32%). The macrophage population was mostly derived from circulating monocytes at all timepoints studied (70% were GFP labeled), while endothelial and vascular smooth muscle cells were partly bone marrow derived (50-60% were GFP labeled), and RPE cells appeared to be entirely derived from preexisting tissue resident cells. These results demonstrate that bone marrow-derived progenitor cells contribute significantly to the vascular and inflammatory components of CNV. Knowledge of the cellular composition and origin might help understand the pathogenic mechanisms controlling CNV severity as well as indicate potential targets for therapeutic intervention.