Eyes Wide Shut: A Cohort Study Questioning the Role of Fundoscopy in Infective Endocarditis Diagnosis.

In this retrospective/prospective study, we assessed the role of fundoscopy in 711 episodes with suspected infective endocarditis (IE); 238 (33%) had IE. Ocular embolic events (retinal emboli or chorioretinitis/endophthalmitis) and Roth spots were found in 37 (5%) and 34 (5%) episodes, respectively, but had no impact on IE diagnosis.

Papilloedema: a highly specific predictor of raised intracranial pressure in a complex neurosurgical paediatric cohort.

PURPOSE: Papilloedema is recognised as an indicator of raised intracranial pressure, although there is a paucity of literature describing the utility of fundoscopy in screening for raised ICP in children with craniofacial synostosis, particularly young children. We sought to investigate the association of optic disc morphology with ICP in children, and to define the sensitivity and specificity of papilloedema as a clinical indicator of raised ICP and determine if age, or underlying conditions impact the findings. METHOD: Retrospective analysis of all patients undergoing ICP monitoring at a designated paediatric neurosurgical and craniofacial unit in the United Kingdom between October 2009 and October 2018. The fundoscopy findings and ICP monitoring data were analysed for 31 children with craniosynostosis and 29 children without craniosynostosis. RESULTS: All children who had papilloedema had raised ICP confirmed with monitoring. Across the 60-patient cohort, confirmed papilloedema on fundoscopy had Positive Predictive Value (PPV) of 1.00, Negative Predictive Value (NPV) of 0.64 with sensitivity 48% and specificity 100% for the presence of raised ICP (p = < 0.0001). In the craniosynostosis group, PPV was 1.00, NPV was 0.39, sensitivity 48% and specificity 100% (p = < 0.03). There is no correlation between severity of optic disc swelling using Frisen grading and elevation of ICP. Age did not affect the presence of papilloedema in those with raised ICP. CONCLUSION: The presence of papilloedema is a strong indicator of raised ICP in a child, regardless of underlying aetiology. Detailed fundoscopy can prevent the need for further investigations including imaging-related radiation and invasive CSF pressure monitoring.

Transorbital point-of-care ultrasound versus fundoscopic papilledema to support treatment indication for potentially elevated intracranial pressure in children.

PURPOSE: To compare transorbital point-of-care ultrasound techniques -optic nerve sheath diameter (US-ONSD) and optic disc elevation (US-ODE)- with fundoscopic papilledema to detect potentially raised intracranial pressure (ICP) with treatment indication in children. METHODS: In a prospective study, 72 symptomatic children were included, 50 with later proven disease associated with raised ICP (e.g. pseudotumour cerebri, brain tumour, hydrocephalus) and 22 with pathology excluded. Bilateral US-ONSD and US-ODE were quantified by US using a 12-MHz-linear-array transducer. This was compared to fundoscopic optic disc findings (existence of papilledema) and, in 28 cases, invasively measured ICP values. RESULTS: The sensitivity and specificity of a cut-off value of US-ONSD (5.73 mm) to detect treatment indication for diseases associated with increased ICP was 92% and 86.4%, respectively, compared to US-ODE (0.43 mm) with sensitivity: 72%, specificity: 77.3%. Fundoscopic papilledema had a sensitivity of 46% and a specificity of 100% in this context. Repeatability and observer-reliability of US-ODE examination was eminent (Cronbach's α = 0.978-0.989). Papilledema was detected fundoscopically only when US-ODE was > 0.67 mm; a US-ODE > 0.43 mm had a positive predictive value of 90% for potentially increased ICP. CONCLUSION: In our cohort, transorbital point-of-care US-ONSD and US-ODE detected potentially elevated ICP requiring treatment in children more reliably than fundoscopy. US-ONSD and US-ODE indicated the decrease in ICP after treatment earlier and more reliably than fundoscopy. The established cut-off values for US-ONSD and US-ODE and a newly developed US-based grading of ODE can be used as an ideal first-line screening tool to detect or exclude conditions with potentially elevated ICP in children.

Effectiveness of simulation models and digital alternatives in training ophthalmoscopy: A systematic review.

PURPOSE: Traditional direct ophthalmoscopy (TDO) is the oldest method of fundus examination; however, it has fallen out of use due to its technical difficulty and limitations to clinical utility, amidst the advent of potentially better options. A spectrum of new technologies may help in addressing the shortcomings of TDO: simulation mannequins with non-tracked TDO, simulation models with tracked TDO, and smartphone ophthalmoscopy (SFO). METHODOLOGY: A systematic search of PubMed, Embase, and Cochrane databases for all studies evaluating usage of simulation mannequins/models and SFO in ophthalmology education was performed, from inception till April 2023 with no language restriction. We ensured that we included all possible relevant articles by performing backward reference searching of included articles and published review articles. RESULTS: We reviewed studies on non-tracked TDO (n = 5), tracked TDO (n = 3) and SFO (n = 12). Non-tracked TDO and SFO were superior in training competency relative to control (TDO on real eyes). Intriguingly, tracked TDO was non superior to controls. SFO appears to enhance the learning effectiveness of ophthalmoscopy, due to real-time projection of the retina view, permitting instantaneous and targeted feedback. Learners reported improved ergonomics, including a wider field of view and more comfortable viewing distance. Retention of images and recordings permitted the audit of learning and paves the way for storage of such images in patients' electronic medical record and rapid dissemination for specialist referral. CONCLUSIONS: Smartphone ophthalmoscopy (SFO) permits integration of both the practice and learning of ophthalmoscopy, and the auditing of both. These advantages over traditional methods (with simulation or otherwise) may lead to a paradigm shift in undergraduate ophthalmology education. However, the nascency of SFO necessitates preservation of traditional techniques to tide through this period of transition.

Needs assessment for direct ophthalmoscopy training in neurology residency.

BACKGROUND: Assessment of the ocular fundus, traditionally by direct ophthalmoscopy (DO), is essential to evaluate many neurologic diseases. However, the status of DO training in neurology residencies is unknown. We conducted a needs assessment to determine current attitudes, curricula, and gaps in DO training. METHODS: A survey was developed and administered to residents and program directors (PDs) at ACGME accredited neurology residencies in the United States. The survey assessed factors such as current DO curricula, perceived importance of DO, confidence of skills, and need for improvement. Data analysis was performed using the Mann Whitney U test and Fisher Exact Test. RESULTS: Nineteen PDs (11.6%) and 74 (41.1%) residents responded to the survey. 97.1% of residents and 100.0% of PDs believe DO is an important skill to learn. 29.4% of PDs expected graduating residents to have completed > 10 supervised DO exams, while 0.0% of graduating fourth year residents reported doing so (p = 0.03). 35.7% of graduating residents had never correctly identified an abnormal finding on DO. The number of times residents practiced DO unsupervised correlated with increasing confidence in all components of the DO exam (p < 0.05). Residents who felt their program emphasized DO were more likely to perform DO at least once a week compared to residents who did not perceive program emphasis (61.9% vs. 35.0%, p = 0.02) and were more confident in DO (p < 0.05). 66.7% of residents and 42.1% of PDs were not satisfied with current levels of DO training. 96.7% of residents and 78.9% of PDs felt it was important to improve curriculum for DO training. Supervised practice and practice skills sessions were identified as the most helpful interventions to improve DO training. CONCLUSIONS: The vast majority of neurology PDs and residents believe DO is an important skill to learn, are unsatisfied with the current level of DO training, and advocate for improvement in DO curricula. Current DO curricula have limited formal didactic training and supervised practice. The bulk of DO learning occurs through unsupervised practice, which is influenced by motivational factors such as perceived residency emphasis on DO learning.

Utility of video-fundoscopy and prospects of portable stereo-photography of the ocular fundus in neurological patients.

BACKGROUND: Proper evaluation of ocular fundi is an integral part of neurological examination. Unfortunately, neurology residents are increasingly uncomfortable performing fundoscopy and interpreting findings because of diminishing skills and lack of experience. This became more prominent during the COVID-19 pandemic as fundoscopy requires proximity to the patient. With the recent dramatic improvement of smartphone cameras, fundus photography using the PanOptic Ophthalmoscope (Welch Allyn, Skaneateles Falls, NY) with a smartphone adapter offered an alternative to direct fundoscopic examination. We present the first experience with our own design of a universal smartphone adapter. METHODS: This is a single-center case series, consecutive for a single user and certain presenting neurological symptoms, which is aimed to evaluate the feasibility and practicality of a new, universal PanOptic smartphone adapter. Presenting symptoms included headache, ocular symptoms, seizure, or encephalopathy. We used 3D modeling and printing techniques to create the adapter. We also developed a methodology of capturing stereoscopic images of the optic disc using a single smartphone camera, but the method was not systematically evaluated in this paper. RESULTS: Here we present our initial experience of fundus video/photography in patients, who presented with encephalopathy, headache, seizure, vision loss, and other ocular symptoms. Fundoscopic abnormalities were discovered in 11 out of 100 patients. Some were incidental findings and were unrelated to the presentation. In one case, fundoscopy played a critical role in establishing the correct diagnosis. CONCLUSIONS: Our custom-designed smartphone adapter allowed obtaining high-quality video and photo recordings using PanOptic Ophthalmoscope. The acquisition of high-quality photos enables a high-yield diagnostic tool and allows revisiting the image in the patient's chart. Improvement of smartphone cameras opens vast horizons for stereo-fundoscopy and 3D reconstruction of the ocular fundus without using sophisticated and costly equipment. Microscopic eye movements allow taking snapshots of two side-by-side photos for 3D reconstruction and stereoscopic image viewing, which is the next level of optic disc assessment.

The role of fundoscopy in pediatric seizures.

Fundoscopy can guide clinicians in the decision to perform neuroimaging. Our aim was to evaluate the rate of abnormal neuroimaging following fundoscopy in children presenting with seizures to the pediatric emergency department (PED). This was a retrospective single-center study. Patients with a discharge diagnosis of seizures were evaluated. Outcome measures were the rate of abnormal brain imaging following a finding of papilledema, and the rate of repeat fundoscopies due to an inconclusive initial examination. A total of 646 patients with seizures underwent fundoscopy. Out of 3 patients who were diagnosed initially with papilledema, only one patient had an abnormal brain CT. He was diagnosed with papilledema previously, and neuroimaging was previously recommended. A total of 7.6% (49/646) of patients underwent a second fundoscopic evaluation. In view of the limited yield and accuracy of fundoscopy in the PED, its role in the clinical decision making in children with seizures is questionable. What is Known: • Seizures are not described as an isolated presenting symptom of increased ICP. • Fundoscopy in children requires skill, time, cooperation. What is New: • Papilledema was found in only one patient who presented with seizures. • Fundoscopy in the PED has limited yield and accuracy in children with seizures.

The eye of the giant anteater (Myrmecophaga tridactyla): Ophthalmic examination findings and diagnostic tests.

OBJECTIVE: To describe ophthalmic examination and diagnostic values for Schirmer tear test (STT), intraocular pressure (IOP), corneal horizontal diameter (CHD), palpebral fissure length (PFL), fundoscopy, and palpebral conjunctiva microbiota from healthy giant anteaters. ANIMALS STUDIED: Twelve giant anteaters (Myrmecophaga tridactyla), 11 adults and one juvenile, five males and seven females. PROCEDURES: The animals were submitted to general anesthesia and ophthalmic evaluation with portable slit-lamp biomicroscope, Finoff transilluminator, and fundoscopy, as well as STT, bacterial culture from palpebral conjunctiva, rebound tonometry IOP, and measurement of PFL and CHD. Data compiled were analyzed with ANOVA and Tukey tests. RESULTS: The results (mean ± standard deviation) were as follows: STT 8.04 ± 6.21 mm/min; IOP 10.92 ± 2.45 mmHg; PFL 0.75 ± 0.11 cm; CHD 0.96 ± 0.10 cm. Out of the 24 eyes swab samples for bacterial culture, 17 were positive, with three genera of Gram-positive bacteria identified Staphylococcus spp., Bacillus sp., and Corynebacterium sp. Gram-negative bacteria were not isolated from any of the samples. CONCLUSIONS: As conservation work in this vulnerable species continues, this report on basic ophthalmic examination and diagnostic parameters will be helpful improve their treatment and care. More ophthalmic studies are encouraged in animals within the Pilosa order.

Perceived usefulness and ease of use of fundoscopy by medical students: a randomised crossover trial of six technologies (eFOCUS 1).

BACKGROUND: Fundoscopy outside ophthalmology is in decline, and the technical demands of the traditional direct ophthalmoscope examination are likely contributing. Alternative fundoscopy technologies are increasingly available, yet valid comparisons between fundoscopy technologies are lacking. We aimed to assess medical students' perceptions of usefulness and ease of use of traditional and contemporary fundus-viewing technologies including smartphone fundoscopy. METHODS: One hundred forty-six second-year medical students participated in a cross-sectional, randomised, cross-over study of fundoscopy methods. Medical students completed small group training sessions using six current fundoscopy technologies including: a non-mydriatic fundus camera; two types of direct fundoscopy; and three types of smartphone fundoscopy. A novel survey of perceived usefulness and ease of use was then completed by students. RESULTS: Repeated-measures ANOVA found students rated both the perceived usefulness (p< 0.001) and ease of use (p< 0.001) of smartphone fundoscopy significantly higher than both the non-mydriatic camera and direct fundoscopy. CONCLUSIONS: Smartphone fundoscopy was found to be significantly more useful and easier to use than other modalities. Educators should optimise student access to novel fundoscopy technologies such as smartphone fundoscopy which may mitigate the technical challenges of fundoscopy and reinvigorate use of this valuable clinical examination.

Development of and Validity Evidence for a Canine Ocular Model for Training Novice Veterinary Students to Perform a Fundic Examination.

Indirect fundoscopy is challenging for novice learners, as patients are often intolerant of the procedure, impeding development of proficiency. To address this, we developed a canine ocular simulator that we hypothesized would improve student learning compared to live dogs. Six board-certified veterinary ophthalmologists and 19 second-year veterinary students (novices) performed an indirect fundic examination on the model and live dog. Prior to assessment, novices were introduced to the skill with a standardized teaching protocol and practiced (without feedback) with either the model (n = 10) or live dog (n = 9) for 30 minutes. All participants evaluated realism and usefulness of the model using a Likert-type scale. Performance on the live dog and model was evaluated in all participants using time to completion of task, performance of fundic examination using a checklist and global score, identification of objects in the fundus of the model, and evaluation of time spent looking at the fundus of the model using eye tracking. Novices (trained on simulator or live dogs) were compared in fundic examination performance on the live dog and identification of shapes in the model. In general, experts performed the fundic examination faster (p ≤ .0003) and more proficiently than the novices, although there were no differences in eye tracking behavior between groups (p ≥ .06). No differences were detected between training on simulator versus live dog in development of fundoscopy skills in novices (p ≥ .20). These findings suggest that this canine model may be an effective tool to train students to perform fundoscopy.

Candidaemia in the elderly: Epidemiology, management and adherence to the European Confederation of Medical Mycology quality indicators.

BACKGROUND: Candidaemia in the elderly has not been extensively investigated. OBJECTIVES: We compared the management of candidaemia in the elderly patients (age ≥65 years) and the very elderly subgroup of patients (age ≥75 years) with those belonging to the younger group (age <65 years) using the European Confederation of Medical Mycology (ECMM) Quality (EQUAL) standard. PATIENTS & METHODS: Over a 10-year period (April 2011-March 2020), patients with candida bloodstream infection were identified. Data pertaining to demographics, clinical risk factors, antifungal treatment, central venous catheter and investigations such as echocardiogram and fundoscopy were obtained from electronic sources and medical case notes. RESULTS: A total of 174 episodes of candidaemia were recorded, comprising of 74 episodes in younger patients and 100 in the elderly, of whom 56 were in the very elderly patients. Of the 177 Candida species recovered, 79 were Candida albicans. EQUAL scores were analysed for 148 patients. The mean score was significantly lower in the elderly (10.4) and the very elderly (9.7) patients compared to the patients in the younger age group (12.19) (P < .01). In particular, this was due to lower blood culture volume drawn (P < .01) and, in the very elderly group, significantly lower scores for the quality indicators pertaining to echocardiogram and fundoscopy (P = .03). The overall mean EQUAL score was 11.16 (median 11; interquartile range 8-14). The 30-day survival was 68% and was similar between all groups. CONCLUSIONS: Areas of improvement were identified in the management of candidaemia in the elderly patients.

Ophthalmic contributions to assessing eyes of two neotropical canids: Cerdocyon thous and Chrysocyon brachyurus.

OBJECTIVE: To describe selected ophthalmic tests and anatomical features of eyes of crab-eating foxes (Cerdocyon thous) and maned wolves (Chrysocyon brachyurus). ANIMALS STUDIED: Six crab-eating foxes (12 eyes), eight maned wolves (16 eyes). PROCEDURES: Intramuscular and/or inhalatory anesthesia, ophthalmic evaluation with portable slit-lamp biomicroscope, Schirmer tear test (STT), intraocular pressure measurement with rebound and applanation (crab-eating fox only) tonometers, measurement of palpebral fissure length (PFL), gonioscopy, and fundoscopy. Data were analyzed with ANOVA and Tukey's tests. RESULTS: Both species presented upper and lower eyelids, both with eyelashes and Meibomian glands openings. A third eyelid was also present. In partial miosis, pigmented projections were observed along the edge of the pupil. The draining angle was open, with thin pectinate ligaments. The retina was holangiotic. For crab-eating foxes, mean ± standard deviation values were as follows: STT: 4.33 ± 2.96 mm/min; PFL: 17.45 ± 1.55 mm; rebound tonometry: 10.70 ± 3.43 mm Hg (TonoVet® calibration D),5.66 ± 3.44 mm Hg (TonoVet® calibration P), 17.00 ± 4.64 mm Hg (TonoVet® Plus calibration dog); and applanation tonometry: 11.70 ± 5.70 mm Hg(TonoPen® XL). For maned wolves, the mean ± standard deviation values were as follows: STT: 9.31 ± 7.40 mm/min; PFL: 22.79 ± 1.63 mm; rebound tonometry: 11.00 ± 2.77 mm Hg (TonoVet® calibration D), 6.78 ± 2.58 mm Hg (TonoVet® calibration P), and 18.29 ± 3.47 mm Hg(TonoVet® Plus calibration dog). CONCLUSIONS: This study contributes with knowledge that can help the clinical assessment regarding eyes of crab-eating foxes and maned wolves. The data herein presented for rebound tonometry are new for both species.

Quality and Feasibility of Automated Digital Retinal Imaging in the Emergency Department.

BACKGROUND: Emergency physicians (EPs) frequently evaluate patients at risk for sight-threatening conditions but may have difficulty performing direct ophthalmoscopy effectively. Digital fundus photography offers a potential alternative. OBJECTIVE: We sought to assess the performance of an automated digital retinal imaging platform in a real-world emergency department. METHODS: We performed a prospective, observational study of emergency department patients who were at risk for acute, nontraumatic, posterior segment pathology. Photographs were obtained using an automated digital retinal camera and were subsequently reviewed by an ophthalmologist. We recorded the number of attempts required, total time required, patient comfort, and findings on EP-performed direct ophthalmoscopy, if performed. RESULTS: Of 123 participants completing the study, 93 (75.6%) had ≥1 eye with a diagnostically useful image, while 29 (23.6%) had no photographs of diagnostic value. The mean number of attempts required to obtain images was 1.45 (range 1-3) and the mean elapsed time required to complete photography was 109.6 s. The mean patient comfort score was 4.6 on a 5-point scale, where 5 was the most comfortable. Direct ophthalmoscopy was performed by an emergency department provider for 19 (15.4%) patients. Acute findings were noted in 14 patients during expert review of fundus photographs, though in only 2 of these cases was direct ophthalmoscopy performed by an EP with only 1 finding ultimately identified correctly. CONCLUSIONS: Automated digital imaging of the ocular fundus is rapidly performed, is well tolerated by patients, and can be used to obtain diagnostic quality images without the use of pharmacologic pupillary dilation in most emergency department patients who are at risk for acute posterior segment pathology.

Validation of a Model for Teaching Canine Fundoscopy.

A validated teaching model for canine fundoscopic examination was developed to improve Day One fundoscopy skills while at the same time reducing use of teaching dogs. This novel eye model was created from a hollow plastic ball with a cutout for the pupil, a suspended 20-diopter lens, and paint and paper simulation of relevant eye structures. This eye model was mounted on a wooden stand with canine head landmarks useful in performing fundoscopy. Veterinary educators performed fundoscopy using this model and completed a survey to establish face and content validity. Subsequently, veterinary students were randomly assigned to pre-laboratory training with or without the use of this teaching model. After completion of an ophthalmology laboratory on teaching dogs, student outcome was assessed by measuring students' ability to see a symbol inserted on the simulated retina in the model. Students also completed a survey regarding their experience with the model and the laboratory. Overall, veterinary educators agreed that this eye model was well constructed and useful in teaching good fundoscopic technique. Student performance of fundoscopy was not negatively impacted by the use of the model. This novel canine model shows promise as a teaching and assessment tool for fundoscopy.

Smartphone fundoscopy with 20 dioptres lens: our experience.

Objective: Assessment of the utility of smartphone fundoscopy in diagnosing posterior pole pathologies. Methods: An iPhone 12 and a 20D Volk lens were used for smartphone fundoscopy. Patients needing bedside consultation were examined with direct ophthalmoscopy and smartphone fundoscopy. Some patients were examined with this technique after slit lamp examination. Results: Over one year 23 bedside fundus examinations were performed and 2 papilledema were diagnosed. After initial slit lamp examination, photos of various pathologies were taken: age-related macular degeneration, branch retinal artery occlusion, arterial embolus, branch retinal vein occlusion, non-arteritic anterior ischemic optic neuropathy, myelinated retinal nerve fiber layer, choroidal naevus. Discussion: With the 20D lens, the image is overturned, magnified 3,13X, and the field of view is 46°. The utility was demonstrated in literature by teaching students this technique and using it in screening for retinopathy of prematurity. The weighted retinal irradiance was measured in two studies. It was 4,6 mW/cm2 in one and from 0,58 to 2,30 mW/cm2 in the other, within safe limits. Conclusions: Smartphone fundoscopy is a fast, accessible, and safe technique for fundus examinations. Other departments could use it for the diagnosis of papilledema.

Unusual Case Report of Headache in 10-Year-Old Female Child.

According to the literature, transverse sinus hypoplasia is not a normal variant and has a serious potential effect on cerebral blood flow. We are presenting a rare case of chronic headache due to severe hypoplasia of the left transverse and sigmoidal sinus. A 12-year-old female girl was admitted with a complaint of gradual progressive severe headache, throbbing in nature, confined to a bitemporal and frontal region in the last 4-5 months. Headache is not associated with fever, vomiting, photophobia, or vision problems. The child had no history of recurrent running nose, refractory vision, ear discharge, head trauma, exanthemata rash, or any drug history. On examination, the child was conscious and oriented. Vital signs are normal. The child was neurologically normal and had no focal signs. Other systemic examinations were normal. Based on History and examination, differential diagnosis was made, like Pseudo tumor cerebri, migraine, deep vein sinus thrombosis, and functional and Posterior fossa tumor. The child had normal routine investigations like complete blood count, electrolyte, and D-dimer. The fundoscopy was normal. In MRI, brain hypoplasia of the left transverse and sinusoidal sinus was suspected and confirmed by MRI venography. Thus, for any patient in an emergency with a chronic headache without focal signs and normal fundoscopy, one deferential should be considered for transverse and sigmoid sinus hypoplasia.

Topology Regulated Background Extraction (TRBE) method for eye fundus images.

One of the initial steps in the preprocessing of digital fundoscopy images is the identification of pixels containing relevant information. This can be achieved through different approaches, one of them is implementing background extraction, reducing the set of pixels to be analyzed later in the process. In this work, we present a background extraction method for digital fundoscopy images based on computational topology. By interpreting binarized images as cubical complexes and extracting their homological groups in 1 and 2 dimensions we identify a subset of luminescence values that can be used to binarize the original grayscale image, obtaining a mask to achieve background extraction. This method is robust to noise and suboptimal image quality, facilitating the analytical pipeline in the context of computer aided diagnosis approaches. This method facilitates the segmentation of the background of a digital fundoscopy image, which allows further methods to focus on pixels with relevant information (eye fundus). This tool is best suited to be implemented in the preprocessing stages of the analytical pipeline by computational ophthalmology specialists.•It is robust to noise and low-quality images.•Output provides an ideal scenario for down-the-line analysis by facilitating only relevant pixels in a digital fundoscopy.

Optical Coherence Tomography Angiography Findings Associated With Accelerated Hypertension.

Introduction Accelerated hypertension, that is a systolic blood pressure greater than 180 mmHg and a diastolic blood pressure greater than 120 mmHg is often accompanied by fundoscopic signs with the potential of systemic and visual morbidity. We report on the clinical and optical coherence tomography angiography (OCTA) findings in a cohort of hypertensive patients with accelerated hypertension. Methods Patients, presenting to the emergency room/intensive care unit, who met the clinical definition of accelerated hypertension (a blood pressure >180/120 mmHg,), were triaged to the intensive care unit. Following blood pressure reduction via pharmacological methods, a standard panel of hematological tests, cardiac evaluation tests, and the necessary systemic imaging was performed. They underwent a bedside dilated fundus examination with subsequent fundus photography/OCTA using a Topcon DRI OCT plus (Topcon Corporation, Tokyo, Japan). The records of these patients were evaluated. Results We analyzed the records of 16 patients (12 males (75%), and four females (25%)) with ages ranging from 16 to 75 years (mean 47.6 years). Eleven patients consented to a detailed evaluation. These included nine males (81.8%) and two females (18.1%) with ages ranging from 16 to 63 years (mean 46.3 years). Comorbidities included pre-existing hypertension (nine patients, 81.8%), chronic kidney disease (three patients, 27.2%), and diabetes mellitus type 2 (two patients, 18.1%). Clinical findings in these 22 eyes included arteriolar changes consistent with Keith Wagener Barker (KWB) grade 1 (two eyes, 9.0%), grade 2 (10 eyes, 45.4%), grade 3 (eight eyes, 36.3%), and grade 4 (two eyes, 9.0%). OCTA findings included capillary nonperfusion in the superficial capillary plexus in the areas of retinal opacification (seven eyes, 31.8%). Conclusion OCTA studies of the macular, as well as the entire posterior pole vasculature, may help to detect retinal microangiopathy, permit accurate grading, and subsequently develop a model that permits the quantification of systemic and ocular risk in these patients.

Mydriasis for retinopathy of prematurity screening in Europe: A cross-sectional online survey.

PURPOSE: To compile real-time data on the preferred mydriasis practice patterns for retinopathy of prematurity (ROP) screening in Europe. METHODS: A cross-sectional online survey was conducted from December 2022 to January 2023, using a self-report online questionnaire which was distributed via email to the members of the European Pediatric Ophthalmological Society and the Greek National ROP Task Force. A six-week period of recruitment was determined, and a reminder email was sent after two weeks. Descriptive statistics were used to explore the data, which was summarized with frequencies and percentages. RESULTS: Sixty-six responses were recorded (response rate: 29.5%), representing practices in 55 Neonatal Intensive Care Units from 21 European countries. In 94.5%, the applied mydriatic regimen consists of phenylephrine with at least one muscarinic antagonist, either tropicamide or cyclopentolate. The concentration of phenylephrine ranges from 0.5% to 5%, of tropicamide from 0.25% to 1%, and of cyclopentolate from 0.2% to 1%. The most commonly used regimen (43.6%) contains phenylephrine 2.5% and tropicamide 0.5%, administered either combined or separately. About 54.5% of the reported mydriatic solutions are non-commercial, in-house preparations. Systemic adverse events, including oxygen desaturation, bradycardia and cardiopulmonary arrest were reported in 14.5%. CONCLUSION: There is considerable heterogeneity in the applied mydriatic regimens for ROP screening in Europe, reflecting the absence of universal guidelines. The wide use of in-house preparations underlines the gap in the pharmaceutical industry. Concern should be raised against the wide use of undiluted commercial drugs, that reach adult dose, in the fragile population of preterm infants.