Unilateral conjunctival Classic Kaposi Sarcoma following a COVID 19 booster.

Purpose: We describe a case of Classic Kaposi's sarcoma in a functionally monocular patient following a COVID19 vaccine booster and provide compelling evidence that suggests the booster was a relevant co-factor in the initiation of the disease process. Observations: The patient presented with red, irritated conjunctival area described as "bubbling" in her right eye. While her past medical history includes hypercholesterolemia and hypertension, she had no history of a compromised immune system. Her ophthalmologic history is more complex including treatment for glaucoma. The patient has 20/20 uncorrected vision OD and LP OS. Due to her ocular co-morbidities, the patient initially received interferon alpha 2-B qid for 6 weeks. However, topical therapy failed to decrease the size of the conjunctival lesions. After referral to Radiation Oncology, the right eye/orbit was treated with electron beam therapy for 1 month which caused a marked decrease in the size and vascularity of the conjunctival lesions. A slow improvement continued during followup. Conclusion and importance: In that the vaccine booster preceded the cancer, it appears etiologic to the appearance of Kaposi's sarcoma. The patient's monocular vision and glaucoma complicated her treatment. This case expands on current concepts of cofactors needed for the development of Kaposi's sarcoma in that vaccine booster administration was relevant to tumor progression and both clinical and mechanistic evidence is presented to support this hypothesis.

Relationship between sleep position and glaucoma progression.

PURPOSE OF REVIEW: As humans spend a considerable portion of life in the horizontal position, it is vital to better understand the effect of sleep position on glaucoma. RECENT FINDINGS: The mean positional increase from the supine position to the lateral decubitus position (LDP) in recent literature is less than 2 mmHg for each eye in its dependent position and less than 1 mmHg in the nondependent position. The right LDP is most commonly favored sleeping position. Some evidence suggests that the positional increases persist and so could lead to worse glaucomatous progression in the dependent eye. However, multiple studies failed to find a strong association. Ideally future research will identify risk factors for higher positional increases to identify patients who may benefit from a change in sleep position. To date, medications and argon laser trabeculoplasty have been ineffective in blunting the positional increase, although glaucoma surgery does reduce it. Raising the head of the bed has been linked with blunting the increase as well. SUMMARY: Certain sleeping positions appear to be associated with higher intraocular pressure, although the association between sleep position and glaucoma progression is not as clear.

A New Rabbit Model of Chronic Dry Eye Disease Induced by Complete Surgical Dacryoadenectomy.

Purpose/Aim: Dry eye disease (DED), common and suboptimally treated, is in need of novel animal models to understand its pathophysiology and assess the efficacy and other parameters of new pharmacological agents for its treatment. The more than 10 rabbit models of DED described to date have significant limitations including induction of mild disease, lack of consistency, and off-target effects when chemical agents are used for disease induction. Our aim was to develop a new model of chronic DED in rabbits that overcomes the limitations of existing models. MATERIALS AND METHODS: We performed a complete surgical resection of all orbital lacrimal glands (LGs; dacryoadenectomy) in normal adult New Zealand White rabbits. One week after removal of the nictitating membrane, we surgically removed the orbital superior LG, followed by removal of the palpebral superior LG, and finally removal of the inferior LG. Surgery was performed under anesthesia, required about 1 h/eye, and was well-tolerated. RESULTS: Dacryoadenectomy induced severe DED, evidenced by >90% reduction in the tear break up time test, 50% reduction in the Schirmer tear test, 10% increase in tear osmolarity, and a marked increase in the rose bengal staining score. DED was sustained and essentially unchanged for the eight weeks of observation. Sham-operated rabbits showed no such changes, with the exception of a non-significant and transient reduction in the tear break up time test, a response to ocular surgery. CONCLUSIONS: This model of stable, chronic, predominantly aqueous-deficient DED recapitulates key clinical and histological features of human DED and is suitable for the study of ocular surface homeostasis, of the pathophysiology of DED, and of the efficacy of candidate drugs for DED treatment.

Similar Performance of Trabectome and Ahmed Glaucoma Devices in a Propensity Score-matched Comparison.

PURPOSE: To apply propensity score matching to Ahmed glaucoma drainage implants (AGI) to trabectome-mediated ab interno trabeculectomy (AIT). Recent data suggest that AIT can produce results similar to AGI traditionally reserved for more severe glaucoma. METHODS: AGI and AIT patients with at least 1 year of follow-up were included. The primary outcome measures were intraocular pressure (IOP), glaucoma medications, and a Glaucoma Index (GI) score. GI reflected glaucoma severity based on visual field, the number of preoperative medications, and preoperative IOP. Score matching used a genetic algorithm consisting of age, sex, type of glaucoma, concurrent phacoemulsification, baseline number of medications, and baseline IOP. Patients without a close match were excluded. RESULTS: Of 152 patients, 34 AIT patients were matched to 32 AGI patients. Baseline characteristics including ethnicity, IOP, the number of medications, glaucoma type, the degree of visual field loss and GI were not significantly different between AIT and AGI. AIT had a preoperative IOP of 23.6±8.1 mm Hg compared with 26.5+10.6 mm Hg for AGI. At 12 months, the mean IOP was 15.0±9 mm Hg for AIT versus 15.0±4 mm Hg for AGI (P=0.8), whereas the number of drops was 2.3±2.2 for AIT versus 3.6±1.3 for AGI (P=0.016). Only 6 AIT patients (17.6%) required further surgery within the first 12 months versus 9 (28%) for AGI. Success, defined as IOP<21 mm Hg, <20% reduction and no reoperation, was achieved in 76% of AIT versus 69% of AGI (P=0.48). Complications occurred in 13% of AGI and 0.8% of AIT. CONCLUSIONS: A propensity score-matched comparison of AIT and AGI showed an equivalent IOP reduction through 1 year. Surprisingly, the AGI group required more glaucoma medications than the AIT group at 6 and 12 months.

A review of teaching methods and outcomes of resident phacoemulsification.

Cataract surgery with phacoemulsification is a challenging procedure for surgeons in training to learn to perform safely, efficiently, and effectively. We review the auxiliary learning tools outside the operating room that residency programs have incorporated into their curriculum to improve surgical skills, including wet laboratory and surgical simulators. We then discuss different methods of teaching cataract surgery in the operating room. Our goal is to define a learning curve for cataract surgery. We demonstrate that complication rates decline significantly after a resident performs an average of 70 cases. We summarize the reported incidence and risk factors for complications in resident-performed cataract surgery to help identify cases that require a higher level of skill to improve visual outcomes. We suggest that future studies include details on preoperative comorbidities, risk stratification, resident skill level, and frequency of takeover by attending.

Longer-term Baerveldt to Trabectome glaucoma surgery comparison using propensity score matching.

PURPOSE: To apply propensity score matching to compare Baerveldt glaucoma drainage implant (BGI) to Trabectome-mediated ab interno trabeculectomy (AIT). Recent data suggests that AIT can produce results similar to BGI which is traditionally reserved for more severe glaucoma. METHODS: BGI and AIT patients with at least 1 year of follow-up were included. The primary outcome measures were intraocular pressure (IOP), number of glaucoma medications, and a Glaucoma Index (GI) score. GI reflected glaucoma severity based on visual field, the number of preoperative medications, and preoperative IOP. Score matching used a genetic algorithm consisting of age, gender, type of glaucoma, concurrent phacoemulsification, baseline number of medications, and baseline IOP. Patients with neovascular glaucoma, with prior glaucoma surgery, or without a close match were excluded. RESULTS: Of 353 patients, 30 AIT patients were matched to 29 BGI patients. Baseline characteristics including, IOP, the number of glaucoma medications, type of glaucoma, the degree of VF loss and GI were not significantly different between AIT and BGI. BGI had a preoperative IOP of 21.6 ± 6.3 mmHg compared to 21.5 ± 7.4 for AIT on 2.8 ± 1.1 medications and 2.5 ± 2.3 respectively. At 30 months, the mean IOP was 15.0 ± 3.9 mmHg for AIT versus 15.0 ± 5.7 mmHg for BGI (p > 0.05), while the number of drops was 1.5 ± 1.3 for AIT (change: p = 0.001) versus 2.4 ± 1.2 for BGI (change: p = 0.17; AIT vs BGI: 0.007). Success, defined as IOP < 21 mmHg, < 20% reduction and no reoperation, was achieved at 1 year in 56% of AIT versus 55% of BGI (p > 0.05) and 50% versus 52% at 2.5 years. CONCLUSIONS: A propensity score matched comparison of AIT and BGI demonstrated a similar IOP reduction through 1 year. AIT required fewer medications.

Use of subconjunctival injections of 5-fluorouracil to rescue and prolong intraocular pressure reduction for a failing Ahmed glaucoma implant.

PURPOSE: 5-Fluorouracil (5-FU) has been well described for a failing trabeculectomy bleb, but not for aqueous shunts. We sought to determine whether subconjunctival 5-FU prolongs the intraocular pressure (IOP) efficacy of Ahmed shunts. METHODS: We included all patients with Ahmed FP-7 implantation by one surgeon at Yale University. Patients with <3 months follow-up were excluded. Injections were done on a case-by-case basis, usually for IOP > 21 on >2 medications. Five-milligram (0.1 cc) injections were made over the plate. The control group consisted of Ahmed FP-7 patients without injections. The main outcome measure was IOP. Secondary outcome was success (IOP <21 mmHg, 20% decrease from preoperative IOP, and no reoperation). RESULTS: The average age of controls was 72.5 ± 16.6 years, and 63.7 ± 18.8 with 5-FU (p = 0.02). Forty-four patients received 5-FU and 45 did not. Mean preoperative IOP in controls was 31.5 ± 11 mmHg on 3.1 ± 1 medications, and 31.9 ± 9.0 mmHg (p = 0.86) on 3.3 ± 0.9 medications with 5-FU (p = 0.18). At a mean 137 days after surgery, mean pre-injection IOP was 25.3 ± 7.7 mmHg on 2.0 ± 1.3 medications. Five years following implantation, control IOPs averaged 12.9 ± 7.1 mmHg (53% decrease from preoperative IOP, p < 0.001) on 1.4 ± 1.1 medications versus 17.2 ± 4.9 mmHg (46% decrease from preoperative, 32% decrease from pre-5FU IOP, p < 0.001) on 2.7 ± 0.8 medications with 5-FU. The IOP at 5 years was statistically similar in both groups (p = 0.23). Five-year success rates trended higher with 5-FU (77 vs. 67%, p = 0.38). CONCLUSIONS: Subconjunctival injection of 5-FU sustained a significant long-term decline in intraocular pressures in eyes with failing Ahmed shunts. Outcomes between eyes receiving injections and controls were statistically similar.

Repeatability of selective laser trabeculoplasty for open-angle glaucoma.

BACKGROUND: To analyze the results of repeat selective laser trabeculoplasty (SLT). INCLUSION CRITERIA: participants with primary or secondary open-angle glaucoma (excluding uveitic) who had undergone SLT 360° (SLT 1) with diminution of response over time followed by repeat SLT 360° (SLT 2). Six months of follow-up were required and at least 6 months in between SLT 1 and 2. The main outcome measures were IOP reduction at 6 and 12 months and a comparison of the response between SLT 1 and 2. RESULTS: One hundred thirty-seven patients met the inclusion criteria. If only one eye had repeat treatment, that eye was chosen; if both eyes qualified, one was chosen at random. The baseline intraocular pressure (IOP) for SLT 1 = 20.3+/- 5.2 mmHg and SLT 2 = 19.4 +/- 5.0 was reduced to 16.4 +/- 3.9 and 16.7 +/- 4.7 at 1 year, respectively (p < .001). Medication use was not significantly changed, and was 2.2 +/- 1.2 at baseline for SLT 1 and 2.1 +/- 1.3 for SLT 2, and at 1 year was 1.9 +/- 1.3 and 2.2 +/- 1.2, respectively. A subanalysis of 62 patients matched for equivalent baselines showed a baseline IOP = 18.7 +/- 3.8 for SLT 1 and 18.7 +/- 3.5 for SLT 2, reduced to 16.0 +/- 4.3 and 15.3 +/- 3.8 at 1 year (p < .001). CONCLUSION: Repeat SLT laser (360-degree treatment, followed by a loss of effect over time, then a second 360-degree treatment) in this population resulted in IOP lowering similar to that of the initial treatment.

Steroid-induced glaucoma treated with trabecular ablation in a matched comparison with primary open-angle glaucoma.

BACKGROUND: To evaluate the outcomes of trabectome-mediated ab interno trabeculectomy in patients with steroid-induced glaucoma (SIG). DESIGN: A retrospective, observational cohort study performed in the Department of Ophthalmology, University of Pittsburgh Medical Center. PARTICIPANTS: The data of 60 patients with SIG and 484 controls with primary open-angle glaucoma (POAG) matched by age, gender and glaucoma index were collected from the Trabectome Study Group database. METHODS: Reduction of intraocular pressure (IOP) and medications were compared between POAG and SIG by multivariate regression. Kaplan-Meier was used for survival analysis. Success was defined as IOP ≤21 mmHg and at least 20% IOP reduction from baseline for any two consecutive visits after 3 months without secondary glaucoma surgery. Postoperative IOP and number of medications were compared with baseline in the SIG subgroups by the Wilcoxon test. MAIN OUTCOME MEASURES: Intraocular pressure reduction and 1-year success rate. RESULTS: Patients with SIG had a higher baseline IOP (31.4 ± 10.4 vs. 24.1 ± 7.6 mmHg, P < 0.01) and obtained a greater IOP reduction than controls with POAG (48.4% vs. 31.5%, P < 0.01). Multivariate regression showed that patients with SIG had an IOP reduction of 6.7 ± 1.1 mmHg more than those with POAG. Survival rates at 12 months were comparable at 86% in the SIG group and 85% in the POAG group (P = 0.47). Patients with SIG with a high baseline IOP, younger age and advanced glaucoma experienced a larger IOP drop. CONCLUSION: Trabectome appears to be an effective surgical treatment in reducing IOP for patients with SIG.

Improved refractive outcomes of postgraduate year 4 cataract surgery after implementing a stepwise biometry lecture series reinforced by self-assessment at a teaching program.

PURPOSE: To determine whether a structured biometry course improves refractive outcomes of resident phacoemulsification. SETTING: Northeast Veterans Administration Hospital, Northport, New York, USA. DESIGN: Retrospective case study. METHODS: Phacoemulsification surgeries performed by residents before and after a biometry curriculum were reviewed. The inclusion criterion was phacoemulsification performed by residents. Patients with fewer than 3 months of follow-up were excluded. The main outcome measure-the mean absolute difference between the target and final refraction-was compared using a linear mixed model. RESULTS: Phacoemulsification surgeries performed by 4 residents before (n = 223) and by 4 residents after (n = 242) a biometry curriculum was implemented were reviewed. All measured preoperative factors were similar in both groups, including age, visual acuity, axial length, steep and flat keratometry values, astigmatism, anterior chamber depth, and lens thickness. Before the biometry course was instituted, 10% of patients had a mean absolute difference of less than 0.25 diopter (D); the percentage was 35% afterward. The mean absolute difference was less than 0.50 D in 40% before the curriculum was initiated and 70% after. The mean absolute difference was less than 1.00 D in 75% before the curriculum was initiated versus 94% after (all P < .05). The corrected distance visual acuities were similar in both groups, with 83% and 80%, respectively, having an acuity of at least 20/25 (P > .05). CONCLUSION: Residents' refractive predictions significantly improved after a formal biometry curriculum, showing that improvements in resident surgical outcomes are possible with structured curriculums reinforcing outcome measures. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Review and meta-analysis of ab-interno trabeculectomy outcomes.

We analysed all of the PubMed publications on ab-interno trabeculectomy (AIT) with the Trabectome (Neomedix, Irvine, California, USA) to determine the reduction in intraocular pressure (IOP) and medications following the procedure. For IOP outcomes, PubMed was searched for 'trabectome', 'ab interno trabeculotomy' and 'ab interno trabeculectomy' and all available papers retrieved. The meta-analysis used a random-effects model to achieve conservative estimates and assess statistical heterogeneity. To investigate complications, we included all abstracts from the American Glaucoma Society, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery and the Association for Research in Vision and Ophthalmology. The overall arithmetic mean baseline IOP for standalone Trabectome was 26.71±1.34 mm Hg and decreased by 10.5±1.9 mm Hg (39% decrease) on 0.99±0.54 fewer medications. Defining success as IOP ≤21 with a 20% decrease while avoiding reoperation, the overall average success rate after 2 years was 46±34%. For combined phacoemulsification-Trabectome, the baseline IOP of 21±1.31 mm Hg decreased by 6.24±1.98 mm Hg (27% decrease) on 0.76±0.35 fewer medications. The success rate using the same definition at 2 years was 85±7%. The weighted mean IOP difference from baseline to study endpoint was 9.77 mm Hg (95% CI 8.90 to 10.64) standalone and 6.04 mm Hg (95% CI 4.95 to 7.13) for combined cases. Despite heterogeneity, meta-analysis showed significant and consistent decrease in IOP and medications from baseline to end point in AIT and phaco-AIT. The rate of visually threatening complications was <1%. On average, trabectome lowers the IOP by approximately 31% to a final IOP near 15 mm Hg while decreasing the number of medications by less than one, with a low rate of serious complications. After 2 years, the overall average success rate is 66%.

Randomized Controlled Comparison of Titanium-Sapphire Versus Standard Q-Switched Nd: YAG Laser Trabeculoplasty.

PURPOSE: To evaluate the clinical effects of laser trabeculoplasty using a novel 790 nm wavelength titanium-sapphire laser (TLT) compared with a 532 nm Q-switched Nd:YAG laser used in standard selective laser trabeculoplasty (SLT). METHODS: Single institution prospective clinical trial of open-angle glaucoma patients randomized to TLT or SLT at the Yale Eye Center from 2011 to 2012. Patients with previous glaucoma surgery or trabeculoplasty were excluded. Trabeculoplasty was performed by a single surgeon unmasked to treatment group. All patients received 360 degrees of treatment. The main outcome measure was intraocular pressure (IOP) at 2 years. RESULTS: Thirty-seven patients were enrolled. The mean baseline IOPs were 19.7 in TLT (n=18) and 20.4 mm Hg in SLT (n=19, P=0.69).At 2 years, the mean IOP was 12.9 mm Hg (35% decrease, P<0.001) in the TLT group and 15.4 mm Hg (25% decrease, P=0.006) in the SLT group. The 2 groups did not differ in glaucoma medication use. Success, defined as IOP<21 mm Hg with >20% reduction from baseline without the need for secondary glaucoma procedures, occurred in 44% of TLT patients and 61% of SLT patients at 1 year and in 22% of TLT patients and 46% of SLT patients at 2 years (P=0.11). No patients experienced significant pain, anterior chamber reaction, corneal edema, or loss of vision. CONCLUSIONS: TLT may be a safe and effective alternative to SLT to lower IOP in patients with open-angle glaucoma.

Early-onset methicillin-resistant Staphylococcus aureus keratitis and late-onset infectious keratitis in astigmatic keratotomy incision following femtosecond laser-assisted cataract surgery.

UNLABELLED: A 79-year-old woman had uneventful femtosecond laser-assisted cataract surgery including paired laser astigmatic keratotomies (AKs) in the right eye. Three weeks postoperatively, a corneal infiltrate developed in the superotemporal AK incision. Cultures grew methicillin-resistant Staphylococcus aureus. The infection was treated with topical fortified vancomycin and tobramycin; full resolution required several months of therapy. Five months after cataract surgery, the patient presented with a second stromal infiltrate, also in the superotemporal AK incision. Despite negative cultures, the infiltrate resolved quickly on a short course of broad-spectrum fortified antibiotics. At 6 months, the corrected distance visual acuity was 20/30. This case demonstrates that infectious keratitis can occur following uneventful femtosecond laser-assisted AK performed concurrently with cataract surgery. We reviewed the literature on infectious keratitis following refractive keratotomy and femtosecond laser-assisted procedures. Several recommendations to prevent these infections are proposed. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Time Spent in Lateral Sleep Position and Asymmetry in Glaucoma.

PURPOSE: To explore sleep position in asymmetric primary open-angle glaucoma (POAG) with a focus on low pressure glaucoma (LPG). METHODS: Sleep laboratory videos of 54 POAG patients were examined for lateral sleep. Then, 29 LPG patients (intraocular pressure [IOP] < 22 mm Hg) with an intereye visual field index (VFI) asymmetry of more than 5% continuously recorded their sleep position at home for 2 nights by using a portable device. Correlations were sought between sleep position, visual field (VF), and retinal nerve fiber layer (RNFL) symmetry as well as ocular biometric data and positional IOP changes. Finally, an expanded data set of 178 POAG patients (63 LPG and 115 high pressure glaucoma [HPG; IOP ≥ 22 mm Hg]) was used to correlate VF and the RNFL symmetry to the self-assessed sleep position collected in a survey. RESULTS: In the video analysis, patients spent 19% ± 2% (mean ± SEM) more time sleeping on one side than on the other. Right-sided sleep was preferred. Right-sided sleep was 1.6 times more common in continuously recorded home data and correlated to an asymmetric VF that was worse in the left eye (b = -0.422, P = 0.002). Pulse amplitude of left eyes was lower in the right decubitus position (P = 0.02). In the expanded survey, 73% of LPG and 58% of HPG patients slept asymmetrically. Right-sided sleepers had a worse RNFL symmetry score. CONCLUSIONS: Asymmetric sleep behavior is common. Right-sided sleep was preferred and correlated with a lower VFI on the left.

Current concepts in the treatment of vitreous block, also known as aqueous misdirection.

Vitreous block (VB), a rare secondary angle-closure caused by anterior rotation of the ciliary body, occurs in a variety of settings, but most frequently after glaucoma filtering surgery. The etiology remains unclear, but choroidal expansion and anterior vitreous abnormalities have been proposed. In the past, treatment of VB has yielded high rates of failure and recurrence. Advancements in surgical techniques, however, have led to improved visual outcomes. We review the history of this condition and present a stepwise approach to its diagnosis and treatment using modern imaging modalities and surgical techniques.

The use of endoscopic cyclophotocoagulation for moderate to advanced glaucoma.

Endoscopic Cyclophotocoagulation (ECP) is a glaucoma surgery designed to reduce the intraocular pressure (IOP) by partially ablating the ciliary processes to decrease aqueous humour production and secretion. The aim of this paper is to review the literature regarding the background, indications and results of the surgery. Although there are case reports of visually devastating complications, including persistent hypotony and phthisis, the use of ECP is often reported in eyes with advanced diseases. When compared with both trabeculectomy and aqueous shunt implantation, the visual outcomes were better with ECP while the IOP outcomes were very similar. The evidence supports ECP as a very effective surgical option in recalcitrant glaucoma while some evidence supports its safety for use as a primary procedure.

Trabeculectomy for traumatic hyphema in sickle cell trait.

A case report of a traumatic hyphema in a patient with sickle cell trait is presented. A review of the published literature in PubMed was performed and medical management strategies and surgical treatment indications for traumatic hyphema are discussed. We support the case for temporary trabeculectomy in patients with traumatic hyphema and sickle cell disease.

A 31-year-old man with bilateral blurry vision and floaters.

We report a case of bilateral multifocal retinochoroiditis and bilateral optic disc edema in a patient with cat-scratch disease from Bartonella henselae. The patient initially had negative serologic testing. Repeat testing showed a markedly increased IgG and IgM convalescent titer and the development of a branch retinal artery and vein occlusion. In patients for whom there is a high clinical suspicion of cat-scratch disease, a convalescent titer should be obtained 2-3 weeks following a negative initial result.