Early Ophthalmology Findings in Nonsyndromic Craniosynostosis.

Craniosynostosis (CS) occurs 1 in 2500 births and surgical intervention is indicated partly due to risk for elevated intracranial pressure (EICP). Ophthalmological examinations help identify EICP and additional vision concerns. This study describes preoperative and postoperative ophthalmic findings in CS patients (N=314) from chart review. Patients included nonsyndromic CS: multisuture (6.1%), bicoronal (7.3%), sagittal (41.4%), unicoronal (22.6%), metopic (20.4%), and lambdoidal (2.2%). Preoperative ophthalmology visits were at M =8.9±14.1 months for 36% of patients and surgery was at M =8.3±4.2 months. Postoperative ophthalmology visits were at age M =18.7±12.6 months for 42% with follow-up at M =27.1±15.1 months for 29% of patients. A marker for EICP was found for a patient with isolated sagittal CS. Only a third of patients with unicoronal CS had normal eye exams (30.4%) with hyperopia (38.2%) and anisometropia (16.7%) at higher rates than the general population. Most children with sagittal CS had normal exams (74.2%) with higher than expected hyperopia (10.8%) and exotropia (9.7%). The majority of patients with metopic CS had normal eye exams (84.8%). About half of patients with bicoronal CS had normal eye exams (48.5%) and findings included: exotropia (33.3%), hyperopia (27.3%), astigmatism (6%), and anisometropia (3%). Over half of children with nonsyndromic multisuture CS had normal exams (60.7%) with findings of: hyperopia (7.1%), corneal scarring (7.1%), exotropia (3.6%), anisometropia (3.6%), hypertropia (3.6%), esotropia (3.6%), and keratopathy (3.6%). Given the range of findings, early referral to ophthalmology and ongoing monitoring is recommended as part of CS care.

Case Report: Significant Complications of Cosmetic Iris Implantation.

SIGNIFICANCE: The complications of cosmetic iris implantation may result in irreversible vision loss. Patients who obtain these implants against general medical consensus may present to providers when sequelae develop. In symptomatic patients, providers must recognize the imminent risk to vision and mitigate further ocular damage. PURPOSE: This is an observational clinical case report of a patient with significant, progressive, vision-threatening ocular pathology from prior cosmetic iris implantation, despite medical and surgical efforts to preserve vision. CASE REPORT: A 35-year-old HIV-positive man with a history of cosmetic iris implants in India 16 months prior was referred to our center. He had a history of 4 months of steroid-refractory uveitis and secondary glaucoma, with IOP measurements of more than 50 mmHg in the outpatient setting. Slit-lamp examination revealed ciliary flush, pannus formation, corneal edema, and keratic precipitates. Optical coherence tomography suggested possible retinal nerve fiber layer loss in the left eye. He was diagnosed with uveitis and glaucoma, and after a short course of IOP-lowering medication, the implants were removed sequentially. Post-operatively, his course was complicated by IOP elevation, cataract development, and corneal decompensation. This led to bilateral Ahmed tube placement, Descemet's stripping endothelial keratoplasty of the right eye, and pending cataract surgery because of now-dense bilateral cataracts. CONCLUSIONS: This case emphasizes the vision-threatening dangers of cosmetic iris implantation. It also demonstrates that sequelae may persist and develop despite implant removal and anticipatory management. Providers managing similar patients should carefully monitor for disease progression and maintain a low threshold for referral and/or decisive surgical intervention.

Effectiveness of a Formal Business of Ophthalmology Course for Trainees.

Objective In medical school and residency training, there is little emphasis on the administrative and business aspects of running a clinical practice as either an employee or a business owner. However, by the first day of practice, young ophthalmologists need to have a basic understanding of the business of medicine to be successful in clinical practice and to avoid common pitfalls. Areas such as risk management, negotiation, financial health, lawsuits, marketing, coding, and professionalism are particularly important for practicing ophthalmologists to grasp. We instituted a formal practice management course to increase the early exposure of our trainees to the business aspects of ophthalmology. Methods Ophthalmology trainees engaged in 11, 1-hour sessions over 3 weeks during a practice management course covering 10 of the most relevant business topics for early career ophthalmologists. A precourse needs assessment, and a postcourse satisfaction and outcomes survey were administered. Results Of the 24 trainees who completed the presurvey, 96% of respondents had no previous training in contract negotiation, 88% lacked training in lawsuits, and 88% had no training in liability insurance. 96% had no inpatient coding education, and 88% had no outpatient coding training. Seventeen trainees completed the postsurvey, and statistically significant improvements in confidence ratings were found in all domains including coding, malpractice claims, and building a practice. 88% of trainees reported that the course improved their ability to code, and 100% agreed that the course improved their understanding of lawsuits, ability to negotiate a contract, and their understanding of the business of ophthalmology. Conclusion A formal, targeted business of ophthalmology course improved the knowledge of trainees on essential business concepts. This course can serve as a model for other programs looking to meet this educational need.

Connections between intrinsically photosensitive retinal ganglion cells and TBI symptoms.

The majority of patients with traumatic brain injury (TBI) are classified as having a mild TBI. Despite being categorized as mild, these individuals report ongoing and complex symptoms, which negatively affect their ability to complete activities of daily living and overall quality of life. Some of the major symptoms include anxiety, depression, sleep problems, headaches, light sensitivity, and difficulty reading. The root cause for these symptoms is under investigation by many in the field. Of interest, several of these symptoms such as headaches, ocular pain, light sensitivity, and sleep disturbances may overlap and share underlying circuitry influenced by the intrinsically photosensitive retinal ganglion cells (ipRGCs). These cells are light sensing, but non-image forming, and they influence corneal function, pupillary constriction, and circadian rhythm. In this review, we discuss these symptoms and propose a role of the ipRGCs as at least one underlying and unifying cause for such symptoms.

Horizontal Transposition of the Vertical Rectus Muscles to Correct a Head Tilt in 5 Patients With Idiopathic Nystagmus Syndrome.

PURPOSE: Patients with idiopathic nystagmus syndrome often develop an abnormal head position. A horizontal face turn can be treated with the augmented Kestenbaum procedure, while patients with a chin up or chin down position can be treated with surgery on the vertical recti and/or oblique muscles. Although rare, some patients may have a head tilt with no face turn. We report 5 patients who underwent horizontal transposition of the vertical rectus muscles to correct a head tilt. DESIGN: Retrospective case series. METHODS: Five cases from 2 different tertiary referral eye centers and 3 different surgeons were reviewed and analyzed. Surgery for the patients consisted of either a 7-mm or full tendon-width transposition of the vertical rectus muscles of each eye to induce cyclotorsion in the direction of the head tilt. The presenting clinical histories, measurements, and surgical outcomes were reviewed. The primary outcome measure was correction of head tilt. RESULTS: Of 5 patients, 2 had previous horizontal face turns that were corrected with an augmented Kestenbaum procedure and later developed a head tilt, while 3 patients presented primarily with a head tilt. Age at surgery ranged from 5 to 8 years. Initial tilts were measured between 20-45°. Surgery was performed bilaterally except in 1 patient with history of morning glory disc anomaly and therefore transposition surgery was only performed on fixating eye for that patient. Postoperatively, 3 of 5 patients had near complete (0-5°) resolution of their tilt. One patient had a persistent 5-degree head tilt and a small chin up that was nullified with vertical prisms in spectacles. CONCLUSION: Transposition of the vertical rectus to induce cyclotorsion in the direction of the head tilt improves abnormal head titling in patients who have idiopathic nystagmus syndrome. This procedure was safely performed in patients with previous augmented Kestenbaum procedures with no incidence of anterior segment ischemia in our cases.

Optical Coherence Tomography Angiography Compared to Fluorescein Angiography in Branch Retinal Artery Occlusion.

A case of embolic branch retinal artery occlusion (BRAO) was evaluated utilizing both fluorescein angiography (FA) and novel optical coherence topography angiography (OCTA). OCTA demonstrated a well-demarcated area of flow interruption secondary to the retinal artery embolus, as well as capillary nonperfusion in the involved region corresponding to FA findings. Therefore, OCTA can demonstrate vascular features of embolic BRAO correlating to FA findings. In this case, OCTA also revealed an increased perfusion defect in the superficial vascular capillary plexus that was not seen on FA.