Acupuncture resulting in eye penetration and proliferative vitreoretinopathy - Surgical and medical management with intraocular methotrexate.

PURPOSE: To highlight the surgical and medical management used in an extensive globe penetrating injury caused by an acupuncture needle. OBSERVATIONS: We report on a case of acupuncture treatment error resulting in needle penetration of the eye, retinal detachment, and progressive post-traumatic proliferative vitreoretinopathy (PVR). This patient required aggressive surgical management with multiple vitrectomies along with adjunctive intravitreal methotrexate to control ongoing PVR. At last follow-up, 15 months after presentation, the patient's BCVA was 20/40 and the periphery was flat with fibrosis stable. CONCLUSIONS AND IMPORTANCE: Open globe injuries are a subtype of ocular trauma which can cause irreparable vision loss. This case highlights the extensive potential complications which can occur following traumatic injury to the retina and choroid, as well as the role of both surgical and medical management of retinal detachment and PVR. In addition, this is the first report of the use of off-label adjunctive intravitreal methotrexate to control post-traumatic PVR. Further research into this treatment approach could reveal a role of adjunctive methotrexate in the management of such injuries.

Optic Nerve Atrophy in N-methyl-D-aspartate (NMDA) Encephalitis.

N-methyl-D-aspartate receptor (NMDA) encephalitis is a recently described autoimmune disease that typically presents with prodromal symptoms including upper respiratory tract infection, headache, fever, nausea, vomiting and diarrhea. Psychiatric symptoms follow within weeks, including anxiety, insomnia, mania, paranoia and grandiose delusions. The diagnosis is confirmed by the detection of NMDA antibodies in the serum or cerebrospinal fluid (CSF).1 Tumours, especially teratomas, are frequently associated with NMDA encephalitis; however, only 5% of male patients older than 18 years have been found to have an underlying tumour. Optic neuropathy associated with NMDA encephalitis is being increasingly recognised in the literature2-6 and was reviewed most recently by Mugavin et al.2 in 2017. In this report, we present a case of bilateral optic neuropathy in a young man diagnosed with NMDA receptor encephalitis.

Tono-Pen versus Goldmann Applanation Tonometry: A Comparison of 898 Eyes.

PURPOSE: To compare the agreement in intraocular pressure (IOP) measurements obtained with the Tono-Pen (Reichert, Inc, Depew, NY) and Goldmann applanation tonometry (GAT). The influence of central corneal thickness (CCT) on IOP agreement between the 2 tonometry methods also was evaluated. DESIGN: Database study. PARTICIPANTS: A total of 898 patients from the Research, Innovation and Experimentation Database spanning 1999 through 2016. METHODS: A total of 898 IOP measurements of right eye obtained with GAT and the Tono-Pen were extracted from a glaucoma, glaucoma suspect, and ocular hypertension clinical database. The agreement between IOP measurements obtained by the 2 methods was analyzed using a Bland-Altman plot in Microsoft Excel (Microsoft, Redmond, WA). Their relationship to CCT was evaluated using linear regression analysis. MAIN OUTCOME MEASURES: Agreement between GAT and Tono-Pen measurements of IOP and influence of CCT on tonometry methods. RESULTS: The correlation between both tonometry devices was 0.76 (P < 0.001). The mean difference (Tono-Pen minus GAT) in IOP measurement was -0.15 mmHg (95% confidence limits, ±6.8 mmHg). The Tono-Pen underestimated GAT measurements at IOP of more than 16.8 mmHg and overestimated at IOP of less than 16.8 mmHg. Larger differences were associated with higher IOPs. An average difference of more than 3 mmHg by the Tono-Pen was observed for IOPs of 29 mmHg or more. A thicker cornea also was associated with higher IOP. A change of 0.16 mmHg for a 10-µm increase in CCT was appreciated for GAT, and one of 0.15 mmHg per 10 µm was appreciated for the Tono-Pen (all P < 0.001). CONCLUSIONS: In a large cohort of more than 898 measurements, the average difference between IOP measured by GAT and the Tono-Pen was less than 1 mmHg, although the limits of agreement were wide. Higher IOPs were associated with larger differences.

A randomised trial of non-mydriatic ultra-wide field retinal imaging versus usual care to screen for diabetic eye disease: rationale and protocol for the Clearsight trial.

INTRODUCTION: Suboptimal screening for diabetic eye disease is a major cause of preventable vision loss. Screening barriers include mydriasis and the extra time patients need to attend dedicated eye screening appointments. In the Clearsight trial, we are testing whether screening by non-mydriatic ultra-wide field (NM UWF) imaging on the day patients attend their diabetes outpatient clinic visit improves detection of clinically important eye disease compared with usual screening. METHODS AND ANALYSIS: Patients with diabetes due for a screening eye exam by the 2013 Canadian Diabetes Association (CDA) practice guidelines are being randomised to on-site screening by NM UWF imaging on the day of their clinic visit or to usual screening where, per CDA guidelines, they are encouraged to arrange an exam by an optometrist. The primary outcome is actionable eye disease (AED) based on a need for referral to ophthalmology and/or increased ocular surveillance. The primary analysis will use an intention-to-screen approach that compares the proportions of detected AED between on-site and usual screening groups under a superiority hypothesis in favour of on-site screening. With 740 randomised participants, the study will have 80% power to detect ≥5% absolute increase in the AED rate among on-site screening versus usual screening participants. This difference translates into a number-needed-to-screen by on-site screening of 20 to detect 1 additional person with AED. ETHICS AND DISSEMINATION: The protocol was approved by the institutional review board of Western University. The findings of the trial will be disseminated directly to participants and through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: ClinicalTrials.Gov NCT02579837 (registered 16 October 2015). PROTOCOL ISSUE DATE: 18 November 2015.