Disease quiescence in endophthalmitis patients treated with anti-VEGF injections for retinal pathologies.

BACKGROUND: The most feared complication of intravitreal injections is the development of endophthalmitis, which could lead to irreversible visual loss. The aim of this study was to characterize the clinical profiles, causative pathogens, and clinical outcome of patients post-endophthalmitis. METHODS: Retrospective, single center case series study. Clinical records, causative pathogens and management of all cases of endophthalmitis post intravitreal anti-vascular endothelial growth factor (VEGF) injections recorded between January 1st, 2006 and May 30th, 2022; were retrieved. The visual and anatomic changes prior to the episode of endophthalmitis and up to 2 years post-treatment were compared. RESULTS: Eleven post-injection endophthalmitis eyes of 10 patients (n = 3 females; 30%) were recruited at mean age of 64.5 ± 20.4 years. The median last recorded BCVA, up to 3 months prior to the episode of endophthalmitis was 60 (Interquartile range (IQR) 55-75) ETDRS letters. Then, it dropped to 30 (IQR 0-57.5), 35 (IQR 0-52.5) and 35 (IQR 0-57.5) ETDRS letters at presentation, 6- and 12-months follow-up; respectively (p = 0.027, p = 0.017 and p = 0.012). However, at 24 months, the median BCVA returned to similar baseline values prior to the episode of endophthalmitis; BCVA 50 (IQR 0-60) ETDRS letters, p = 0.062. Interestingly, two eyes with neovascular age-related macular degeneration (NVAMD), 1 with myopic choroidal neovascularization (CNV) and 1 with retinal vein occlusion (RVO), experienced disease quiescence and did not require additional anti-VEGF injections up to 2 years of follow-up. CONCLUSION: This study demonstrates long-term recovery of vision loss due to endophthalmitis post anti-VEGF injections, regained up to 2 years later. It also indicates that disease quiescence post endophthalmitis may not only occur in eyes treated for NVAMD, but also with myopic CNV and RVO.

Suppressing Inflammation for the Treatment of Diabetic Retinopathy and Age-Related Macular Degeneration: Dazdotuftide as a Potential New Multitarget Therapeutic Candidate.

Diabetic retinopathy (DR) and age-related macular degeneration (AMD) are major causes of blindness globally. The primary treatment option for DME and neovascular AMD (nAMD) is anti-vascular endothelial growth factor (VEGF) compounds, but this treatment modality often yields insufficient results, and monthly injections can place a burden on the health system and patients. Although various inflammatory pathways and mediators have been recognized as key players in the development of DR and AMD, there are limited treatment options targeting these pathways. Molecular pathways that are interlinked, or triggers of multiple inflammatory pathways, could be promising targets for drug development. This review focuses on the role of inflammation in the pathogenesis of DME and AMD and presents current anti-inflammatory compounds, as well as a potential multitarget anti-inflammatory compound (dazdotuftide) that could be a candidate treatment option for the management of DME and AMD.

Uveitis in Children: The Role of Biological Agents in Its Management.

We aimed to determine medium and long-term effects of TNF-α inhibitors in patients with pediatric uveitis. This was a retrospective review of medical charts. Included were 50 patients (84 eyes). Mean age at diagnosis was 7.22 ± 4.04 years. At baseline (time of initiation of biologic therapy), all patients had active uveitis. Complete control of uveitis was achieved in 84.52% (n = 71) of eyes, after a median of 3 months (IQR 2 months). Mean LogMAR BCVA at baseline was 0.23 ± 0.44; it remained stable at 12 and 24 months. At baseline, 64% of patients were treated with oral corticosteroids, this decreased to 29.5% at 12 months (p = 0.001) and to 21.9% at 24 months (p < 0.001). Mean time to prednisone dose of ≤0.2 mg/kg/day was 8.1 ± 2.02 months after baseline. A total of 40.5% of eyes were treated with topical steroids at baseline and this significantly decreased to 5.8% at 12 months. Multiple linear regression model was calculated to predict moderate and severe visual loss; only presenting visual acuity accounted for a unique variance in the model. In conclusion, TNF-α inhibitors achieved rapid disease control while enabling a remarkable steroid-sparing effect in children suffering from chronic uveitis. Presenting visual acuity was the sole predictor of moderate to severe visual loss.

Long-term Experience with Anti-tumor Necrosis factor- α Therapy in the Treatment of Refractory, Non-infectious Intermediate, Posterior, and Panuveitis.

PURPOSE: To study the efficacy and long-term effects of infliximab and adalimumab in patients with active refractory non-infectious intermediate, posterior, or panuveitis (NIPPU). METHODS: Retrospective, longitudinal study. RESULTS: Included were 61 patients (104 eyes) of whom 34 were males (55.74%). Mean age at diagnosis of uveitis was 26.5 ± 16.14 years. All patients had active uveitis at baseline (time of initiation of biological therapy). Median interval between the start of conventional immunomodulatory therapy (IMT) to the introduction of biological therapy was 13.0 (IQR 26.0) months. Ocular inflammation was effectively controlled in 92 eyes (88.46%). The most commonly used TNF-α inhibitor was adalimumab in 47 patients (77%). Mean follow-up time after baseline was 40 ± 34.08 months. In the year preceding the institution of TNF-α inhibitors, the average number of flares was 1.5 ± 1.1/year and it decreased to 0.08 ± 0.29/year in the first year after baseline (p < .0005). Forty-four eyes (42.30%) experienced flare over the entire follow-up period. Mean time to first flare was 14.5 ± 9.26 months. At baseline, the mean dose of prednisone was 25.5-±20.8 mg/day. A marked decrease to a mean prednisone dose of 7.85 ± 9.7 mg/day was observed at 6 months (p = .03). In patients treated with adalimumab, the mean time to prednisone dose ≤7.5 mg/day was 4.02 ± 4.89 months compared to 15.64 ± 21.34 months in patients treated with infliximab (p = .03). 64.3% of patients treated by infliximab had Behçet uveitis compared to 27.7% of patients treated by adalimumab. Eyes treated with adalimumab experienced first flare at a mean time of 14.11 ± 6.29 months, whereas eyes treated with infliximab experienced first flare at 18.29 ± 14.24 months after baseline (p < .0005). The risk for moderate and severe visual loss was lower with shorter duration of uveitis before initiating anti-TNF-α treatment (odds ratio, 0.003; 95% CI, 0.000-0.005; p = .023), better presenting logMAR VA (odds ratio, 0.266; 95% CI, 0.172-0.361; p < .0005) and when adalimumab was used (odds ratio, 0.354; 95% CI, 0.190-0.519, p < .0005). CONCLUSIONS: Anti-TNF-α therapy was successful in controlling refractory NIPPU in the majority of cases. It significantly reduced flare rate, exerted steroid-sparing effects, and preserved visual potential. Adalimumab use, better initial visual acuity, and earlier introduction of anti-TNF- α therapy were associated with a lower risk of visual loss.

Interest of Widefield-Optical Coherence Tomography Angiography for Diagnosis and Follow-Up of Retinal Neovascularisation in Proliferative Diabetic Retinopathy.

Aim: The primary aim was to evaluate the use of optical coherence tomography angiography (OCTA) versus fluorescein angiography (FA) for detecting and monitoring retinal neovascularization (NV) in patients with proliferative diabetic retinopathy (PDR) receiving treatment with anti-vascular endothelial growth factor (anti-VEGF). Methods: Treatment-naïve patients with PDR, willing to begin anti-VEGF treatment without laser from 9/2018-2/2020 were included. FA and OCTA scans were obtained at baseline, and a second OCTA scan was performed after 6 months of anti-VEGF therapy. We calculated sensitivity and specificity for two masked graders with respect to identifying NV on OCTA versus FA. Using ImageJ software, we also measured the change in NV size, at baseline and 6-month follow-up. Results: Ten eyes in eight patients were included, of which three eyes in three patients received a 6-month follow-up examination. Mean age was 51.7 ± 11.2 years, and 75% of patients were male. Overall, 21 NV sites in the 10 eyes were identified both clinically and on FA. Using OCTA scans, the sensitivity and specificity for both graders were extremely high, ranging from 95.2% to 100%. At 6-month follow-up, NV size decreased by 69.8%. Conclusion: These results suggest that OCTA may provide a suitable alternative to FA for visualizing, measuring, and monitoring changes in retinal NV in patients with PDR who receive anti-VEGF therapy.

Outer Retina Rupture from Subretinal Blood with Spontaneous Sealing and Visual Recovery in Frosted Branch Angiitis from Familial Mediterranean Fever: A Case Report.

Familial Mediterranean fever (FMF) is a rare autoinflammatory disorder. Ocular involvement is rare. The full spectrum and response to treatment is poorly understood. An 18-year-old girl previously diagnosed with FMF presented with sudden loss of vision in the left eye (LE). Best-corrected visual acuity (BCVA) in the LE was finger counting at 1.5 meters. Angiitis with mild "frosting," hemi-central retinal vein occlusion (HCRVO), and acute outer retina rupture (ORR) were observed in the LE. Systemic steroids were initiated immediately. The ORR was sealed 2 weeks later while vision improved to 6/15 (near vision: J2) 5 months later. No recurrences were observed over 5 years of follow-up. We report a rare manifestation of frosted branch angiitis with concomitant HCRVO and ORR in a young patient with FMF. Closure of ORR was attained and vision recovered after treatment with high-dose steroids.

Evidence-Based Medicine in the Field of Ophthalmology during the COVID-19 Pandemic.

Purpose: To describe the evolution of COVID-19 related publications in the field of ophthalmology. Methods: All articles published in the field of ophthalmology and relevant to COVID-19 were identified by conducting a search on PubMed and Scopus databases using the string ((ophthalmology) OR (eye) OR (ocular)) AND ((corona) OR (COVID-19) OR (pandemic)). Search was conducted on September 30, 2020. Each eligible publication was independently graded by two experienced ophthalmologists based on the level of evidence-based medicine (EBM), with scores ranging from 1 (the highest level of EBM) to 5 (the lowest level). The average level of EBM was also evaluated for each month from February through September. Finally, we analyzed the interval (in days) between submission and acceptance for publication as well as the percentage of manuscripts that required revision before being accepted. Results: Our search yielded a total of 425 relevant publications. Of these publications, 359 (84.5%), 59 (13.9%), and 7 (1.6%) were rated as level 5, 4, and 3, respectively; none of the publications was rated as level 1 or 2. From February 2020 through September 2020, we found a significant increase in the relative proportion of level 3 and 4 publications compared to level 5 publications (rho = 0.108, p=0.024). Moreover, the number of citations per article was significantly correlated with the level of EBM (rho = 2.44, p < 0.0005); however, we found no correlation between the number of citations and either the month of publication or the ranking of the journal in which the article was published. The mean interval between submission and acceptance for publication was 20.4 days (SD: 20.2 days), and 48.2% of submitted manuscripts were accepted without revision. From February through September, the interval between submission and acceptance increased significantly (rho = 0.515, p < 0.0005); however, we found no significant change in the percentage of publications that were accepted without revision over this same time period. Conclusions: In the early months of the COVID-19 pandemic, primarily lower-level EBM articles were published, and these publications were accepted relatively quickly. However, this effect was temporary, and over time the EBM levels improved and the interval between submission and acceptance increased, indicating an increase in publication standards.

The detrimental effects of delayed intravitreal anti-VEGF therapy for treating retinal pathology: lessons from a forced test-case.

PURPOSE: Determine the anatomical consequences of delaying intravitreal injection (IVI) therapy with anti-vascular endothelial growth factor (anti-VEGF) in patients using treat-and-extend (T&E) protocol. METHODS: Retrospective medical record review of consecutive patients receiving intravitreal anti-VEGF therapy using T&E protocol prior to and during the COVID-19 pandemic. RESULTS: The study included 923 eyes of 691patients; 58.8% (543 eyes), 25% (231 eyes), and 16.2% (149 eyes) had nvAMD, DME, and RVO, respectively. Mean (± SD) patient age was 74.5 ± 11.7 years. Overall, 56.3% of cases had a delay in therapy of ≥ 7 days; specifically, 56.2%, 61.5%, and 49.0% of nvAMD, DME, and RVO cases, respectively, had a delay. The median delay in days, among cases ≥ 7 days late was 21 (IQR 7 to 42) days, with 21(IQR 7 to 45), 22.5(IQR 8 to 42), and 14(IQR 7 to 33.5) days of delay among patients with nvAMD, DME, and RVO, respectively. Delaying therapy by ≥ 7 days resulted in increased CST in 47.5%, 58.5%, and 58.9% of nvAMD, DME, and RVO cases, respectively, with a significant correlation between the length of treatment delay and the increase in CST (Spearman's rho: 0.196; p < 0.001). CONCLUSIONS: Delayed IVI treatment in eyes treated with T&E protocol was associated with increased macular thickness with potential consequences with respect to visual outcome.

Ophthalmic Emergency Visits in the Wake of the COVID 19 Pandemic: Our Experience at a Tertiary Hospital in Israel.

BACKGROUND: In response to the coronavirus disease-2019 (COVID-19) pandemic, routine clinical visits to the ophthalmic emergency department (OED) were deferred, while emergency cases continued to be seen. OBJECTIVES: To assess the consequences of the COVID-19 pandemic for ophthalmic emergencies. METHODS: A retrospective chart analysis of patients who presented to the OED during the peak of the COVID-19 pandemic was conducted. The proportions of traumatic, non-traumatic-urgent, and non-traumatic-non-urgent presentations in 2020 were compared to those of the same time period in 2019. Duration of chief complains and best-corrected visual acuity were also assessed. RESULTS: There were 144 OED visits in 2020 compared to 327 OED visits during the same 3-week-period in 2019. Lower mean age of OED patients was present in 2020. Logarithmic expression (LogMAR) best corrected visual acuity (BVCA) was similar in both years. In 2020 there was a reduction in traumatic, non-traumatic-urgent, and non-traumatic-non-urgent cases compared to 2019 (15.4% reduction, P = 0.038; 57.6% reduction, P = 0.002; 74.6% reduction, P = 0.005, respectively). There was a higher proportion of same-day presentations at commencement of symptoms in 2020 compared with 2019 (52.8% vs. 38.8%, respectively P = 0.006). CONCLUSIONS: During the COVID-19 pandemic, the number of OED visits at a tertiary hospital dropped by more than half. Although the drop in visits was mostly due to decrease in non-traumatic-non-urgent cases, there was also decrease in non-traumatic-urgent presentations with possible important visual consequences. Additional studies should elucidate what happened to these patients.

Clinical outcome using a modified treat-and-extend protocol for neovascular age-related macular degeneration.

AIM: To compare outcome between patients treated using a modified treat-and-extend (mT&E) protocol and patients treated using a conventional T&E protocol. METHODS: A retrospective cohort study of two groups of treatment-naïve neovascular age-related macular degeneration patients within a single centre were evaluated. One group treated using the conventional T&E protocol, with visual acuity, dilated fundus examination (DFE) and optical coherence tomography (OCT) performed at each visit. The second group treated using the mT&E protocol in which visual acuity and DFE were performed only every three visits. The main outcome measures were time spent per clinical visit, visual and anatomical outcomes measured for 36 months. RESULTS: The T&E and mT&E groups included 135 eyes in 116 patients and 119 eyes in 94 patients, respectively, with similar baseline characteristics. At 36 months, the number of injections administered (7.9±2.9 vs 8.1±2.3 injections, respectively; p=0.55), the percentage of eyes that gained ≥15 Early Treatment for Diabetic Retinopathy Study (ETDRS) letters (23% vs 25.2%, respectively; p=0.39) and the percentage of eyes that lost ≥15 ETDRS letters (21.5% vs 17.7%; p=0.43, respectively) were similar between the T&E and mT&E groups. However, waiting and contact time were reduced during the OCT-only visits compared with the full visits, with an average of 41 min saved per patient encounter. CONCLUSIONS: Both protocols yielded similar visual and anatomical outcomes. However, the mT&E protocol reduced the number of full visits, with considerably less time spent at the clinic.

Long-term outcome of neovascular age-related macular degeneration: association between treatment outcome and major risk alleles.

AIMS: To evaluate the long-term functional and anatomical outcomes of neovascular age-related macular degeneration (nvAMD) treated with intravitreal anti-vascular endothelial growth factor (anti-VEGF) for up to 10 years, and to identify associated risk factors. METHODS: Clinical and optical coherence tomography findings were retrieved for nvAMD cases treated with intravitreal anti-VEGF compounds using a treat-and-extend protocol. In addition, the major risk alleles for AMD in the CFH (rs1061170), HTRA1 (rs1200638) and C3 (rs2230199) genes were genotyped. RESULTS: From 276 eligible eyes in 206 patients, 80 eyes (29%) in 66 patients (32.0%) had a follow-up period of ≥8 years and were included in this study. Over a 10-year period, 73.3±28.0 (mean±SD) anti-VEGF injections were administered. Best-corrected visual acuity (BCVA; LogMAR) deteriorated from 0.55±0.53 at baseline to 1.00±0.73 at 10 years (p<0.0005). Central subfield thickness (CST) decreased from 415.8±162.1 µm at baseline to 323±113.6 µm (p<0.0005) after three monthly injections and remained lower than baseline throughout the follow-up period. Visual outcome was associated with BCVA and intraretinal fluid (IRF) at baseline, macular atrophy, and macular thinning at follow-up. The decrease in CST was inversely correlated with the number of CFH and/or C3 risk alleles carried by the patient (Pearson's r: -0.608; p=0.003). CONCLUSIONS: Patients with nvAMD who received anti-VEGF therapy for 10 years developed substantial vision loss associated with the presence of IRF at baseline and macular atrophy. Major risk alleles for AMD in two complement genes were associated with a reduced long-term reduction in macular thickness.

Visual assessment of commercial drivers in the South West Region of Cameroon.

BACKGROUND: Driving is a visually intensive task. In Cameroon, where the burden of road traffic deaths is high, visual assessment is not universally performed before the issuance of driver licenses. This study aims to assess the visual status of commercial drivers (CDs) in the southwestern region of Cameroon, and to find its relation to road traffic crashes (RTCs). METHODS: This work was a cross-sectional community-based study on CDs in Limbe and Buea. Questionnaires were used to assess sociodemographic parameters, the incidence of RTCs, and self-reported visual status. Visual acuity (VA) was measured using a standard Snellen chart at 6 m. Statistical analysis was performed using descriptive methods: frequencies, the paired Student's t-test, and the chi-square test. RESULTS: Two hundred seven CDs were enrolled in this study, all of which were male, with a mean age of 41.8 ± 12.1 years. A total of 15.0% had undergone an eye exam prior to licensure, and 3.4% had undergone an eye exam within the past 10 years. The VA in the better-seeing eye of participants was less than 6/9 and 6/12 in 14.1 and 10.6% of CDs, respectively. Seventy-five percent of CDs with self-reported poor vision and 95% of CDs with VA < 0.5 had a history of RTCs compared to 55.8% of CDs with self-reported good vision and 55.7% of CDs with VA ≥ 0.5 (p < 0.05). Injuries from RTCs were more common in CDs with self-reported poor vision (81.1%) and in those with VA < 0.5 (90.5%) compared to CDs who self-reported good vision (55.8%) and those with VA ≥ 0.5 (55.7%) (p < 0.05). CONCLUSIONS: A large proportion of CDs did not undergo a visual assessment before the issuance or renewal of their driver licenses. A substantial number of CDs had poor vision in their better-seeing eye and suffered from RTCs and related injuries, which suggests that the visual status of CDs in Cameroon is related to the gruesome number of road traffic crashes and deaths in the country. Therefore, concerned authorities should consider making vision tests a necessary requirement for the obtention of driver licenses.

High umbilical cord blood lead levels and "calabar chalk" consumption amongst pregnant women in two hospitals in Cameroon.

INTRODUCTION: "Calabar chalk" is a lead-laden pica mostly consumed by pregnant women worldwide as a remedy for morning sickness. This clay material has been shown to have lead levels of up to 40mg per kilogram. Meanwhile blood lead levels, even at doses less than 10µg/dl will be toxic to humans and even worse-off to the fetus as it crosses the placenta. We, therefore, sort to determine the prevalence of "Calabar chalk" consumption amongst pregnant women and if it translates to higher umbilical cord blood lead levels. METHODS: We carried out a cross-sectional study by prospectively and consecutively enrolling 300 pregnant women from December 2014 through February 2015. A questionnaire was administered to ascertain "Calabar chalk" consumption. The levels of lead in the umbilical cord blood of 51 participants of each group of those who consumed and didn't consume "Calabar chalk" were measured by spectrometry and compared using the T-test (p<0.05). RESULTS: The prevalence of "Calabar chalk" consumption was 43.33%. This was mostly consumed during pregnancy only (46.34%), with higher rates observed amongst primigravidas. The mean umbilical blood lead levels amongst those who consumed and those who did not consume "Calabar chalk" was 39.19µg/dl and 25.33µg/dl respectively (P=0.111). CONCLUSION: The prevalence of "Calabar chalk" consumption was high in the pregnant women population. The overall umbilical cord blood lead levels were extremely high in both consumers and non-consumers. We recommend health education and chelation therapy to be considered.

Acute blindness as a presenting sign of childhood endemic Burkitt's lymphoma in Cameroon: a case report.

BACKGROUND: Endemic Burkitt's lymphoma is found predominantly in malaria holoendemic zones, typically in the tropical rain forest of Africa. It usually presents as an extra-nodal tumour in children and young adults with predilection for jaws and soft tissues of the abdomen. Clinical features depend on the primary tumour site, extent of the disease and histologic subtype. Acute blindness as a presentation sign is rare. CASE PRESENTATION: A 13 year old African female presented to our facility with a 3 week history of painful abdominal distention, and loss of vision of the left eye. On examination, there was a huge abdominopelvic mass, left breast mass and complete blindness of the left eye associated with mydriatic pupils non-responsive to light. An abdominal ultrasound showed a huge hypoechoic mass arising from the pelvis and protruding into the abdomen. The jaws, teeth and maxilla were all normal. A fine needle aspiration done was negative for malignant cells. A presumptive diagnosis of Burkitt's lymphoma was made on clinical grounds and abdominal ultrasound findings. The patient was immediately placed on chemotherapy and responded well to treatment with remission of the tumour but persistence of left eye blindness. CONCLUSION: Acute blindness can be the presenting sign of Burkitt's lymphoma in a patient with neither jaw nor maxillary swelling. Primary healthcare providers in low income settings require a high index of suspicion when faced with such atypical presentations. This emphasizes the need for thorough physical examination, and when possible, the clinical utility of ultrasonography for suspicious abdominal masses in the absence of state-of the art diagnostic tools for early diagnosis and treatment, which is critical for survival and to improve quality of life.

Awareness of breast cancer and breast self-examination among female undergraduate students in a higher teachers training college in Cameroon.

Introduction: The incidence of breast cancer (BCa) in Cameroon is on the rise and accounts for a leading cause of mortality. An understanding of the knowledge and practices on breast cancer and breast self-examination (BSE) among teachers are important first steps which will guide the designing of interventions aimed at raising awareness across the general population. Methods: We conducted a cross-sectional study in April 2016 involving 345 consenting female undergraduate students in the Higher Teachers Training College, Bambili, Cameroon. Data was collected using a pretested self-administered questionnaire and analysed using descriptive methods. Results: The mean age of the respondents was 22.5±3.2years and a vast majority (n = 304, 88.1%) had heard about BCa primarily from the television/radio (n=196, 64.5%). Overall, less than a quarter (n=65, 21.4%) of respondents who had heard about BCa had sufficient knowledge on its risk factors and signs/symptoms. A plurality (53.3%) thought BCa can be prevented via vaccination while over a third (38.7%) opined that BCa can be treated spiritually. Less than half (47%) of respondents who had heard about BCa had heard about BSE amongst which only 55 (38.5%) had ever practiced it. Conclusion: Though most students are aware of the existence of breast cancer, their overall knowledge on its risk factors and clinical presentation is insufficient with a concomitant low practice of BSE. These highlighted gaps warrants intensification of sensitization campaigns and educational programmes in order to raise knowledge levels and enhance prevention strategies that would aid in reducing the burden of breast cancer in Cameroon.