Primary ocular toxoplasmosis secondary to venison consumption.

Purpose: To describe primary ocular toxoplasmosis infection related to ingestion of undercooked venison. Observations: This single site, retrospective case series reviewed 4 patients with primary ocular toxoplasmosis that was acquired by ingesting undercooked venison. De-identified data was collected regarding baseline patient characteristics including age, sex, past medical and ocular history, onset of symptoms, visual acuity (VA), response to treatment, and workup. All patients with acquired toxoplasmosis had similar chronology of systemic and ocular symptoms. Exposure occurred in October or November and systemic symptoms developed within 2 weeks, followed by ocular symptoms an average of 2.6 months later. Average age at onset was 56 ± 13 (age ± SD) years old and all were male. Average initial and final VA were 20/50 and 20/50, respectively. Positive anti-toxoplasma IgM and IgG serologies were found in all cases. All patients were treated with trimethoprim/sulfamethoxazole and achieved rapid improvement. Complications occurred in 50% of cases and included epiretinal membrane, cystoid macular edema, vitreoretinal traction, and neovascularization. Conclusions and importance: Consumption of undercooked venison is a source of primary ocular toxoplasmosis even in immunocompetent hosts and has a clear chronology. A presentation of retinochoroiditis during the winter months should prompt questioning for exposure to wild game.

Reading Speed as an Objective Measure of Improvement Following Vitrectomy for Symptomatic Vitreous Opacities.

BACKGROUND AND OBJECTIVE: There is currently no objective measure of the visual deficits experienced by patients with symptomatic vitreous opacities (SVOs) that would also correlate with the functional improvement they report following vitrectomy. This study aims to determine whether reading speed can be used as a reliable outcome measure to assess objectively the impact of both SVOs and vitrectomy on patients' visual performance. PATIENTS AND METHODS: Twenty adult patients seeking surgery for SVO were included. Measures of visual function were obtained before and after vitrectomy using the Early Treatment Diabetic Retinopathy Study acuity chart, the National Eye Institute Visual Function Questionnaire, and the MNREAD acuity chart. RESULTS: In patients with nonopacified lenses (n = 10), maximum reading speed increased significantly from 138 to 159 words per minute after complete removal of SVOs by vitrectomy (95% confidence interval, 14-29; P < .001). CONCLUSIONS: Reading speed is impaired with SVOs and improves following vitrectomy in phakic and pseudophakic eyes with clear lenses. Reading speed is a valid objective measure to assess the positive effect of vitrectomy for SVOs on near-distance daily life activities. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:456-466.].

PREDICTIVE FACTORS FOR PROLIFERATIVE VITREORETINOPATHY FORMATION AFTER UNCOMPLICATED PRIMARY RETINAL DETACHMENT REPAIR.

PURPOSE: To determine predictive factors of proliferative vitreoretinopathy (PVR) formation after uncomplicated primary retinal detachment repair. METHODS: Retrospective, single-center, case-control study of 74 consecutive patients with (37 eyes) and without (37 eyes) PVR formation after undergoing uncomplicated primary surgery for retinal detachment repair. Logistic regression was used to assess factors associated with PVR formation. RESULTS: Retinal detachment involving the macula was 4.2 times (adjusted odds ratio; 95% confidence interval, 1.4-12.9; P = 0.0119) more likely to have PVR formation compared with those without. Patients who were current or former smokers were 3.6 times (adjusted odds ratio; 95% confidence interval, 1.1-11.7; P = 0.0352) more likely to have PVR formation compared with nonsmokers. Compared with 25-gauge (g) vitrectomy, larger gauge vitrectomy (20 g or 23 g) was 3.6 times (adjusted odds ratio; 95% confidence interval, 1.2-11.3; P = 0.0276) more likely to have PVR formation. Duration of retinal detachment symptoms, high myopia, lens status, lattice degeneration, location of retinal break, number of retinal breaks, and surgical technique (e.g., scleral buckle with or without vitrectomy versus vitrectomy alone) were not found to be predictive of PVR formation. CONCLUSION: Cigarette smoking and macular involvement are significant risk factors predictive of PVR formation after uncomplicated primary retinal detachment repair.

Endophthalmitis after Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitors: Management and Visual Outcomes.

PURPOSE: We describe the presentation of patients developing endophthalmitis after intravitreal injection with vascular endothelial growth factor (VEGF) inhibitors. Moreover, we evaluate the management by comparing the outcomes of immediate tap and injection of intravitreal antibiotics (TAI) versus initial surgical pars plana vitrectomy (PPV). Finally, we analyze the predictive factors of visual outcomes at 6-month follow-up. DESIGN: Retrospective, single-center, nonrandomized interventional study. PARTICIPANTS: Patients developing endophthalmitis after receiving an intravitreal injection of anti-VEGF agent between 2006 and 2016. METHODS: All patients received a vitreous biopsy sent for cultures before the initiation of treatment: TAI group versus PPV with intravitreal antibiotics (PPV group). MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA) at 6-month follow-up after treatment for endophthalmitis. RESULTS: A total of 258 357 intravitreal injections occurred over the course of the 10-year period, of which 40 patients (0.016%) had endophthalmitis within 3 weeks after injection. In total, 34 patients (85.0%) had pain and 25 patients (62.5%) had hypopyon on initial examination. Among 24 culture-positive cases, 66.7% of the causative organisms were coagulase-negative Staphylococcus, followed by Streptococcus species (10.0%). The best-corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution [logMAR]) at 6-month follow-up was significantly worse for patients who had a positive culture for Streptococcus species (4.0; standard deviation [SD], 0.8) (approximately light perception) compared with those who had a positive culture for coagulase-negative Staphylococcus (0.4; SD, 0.3) (∼20/50) (P < 0.0001). Compared with the TAI group, a higher proportion of samples were culture-positive in the PPV group (90.9% vs. 48.3%, P = 0.03). There was no statistically significant difference in BCVA at 6-month follow-up between the TAI and PPV groups. Younger age (<85 years) and lower intraocular pressure (IOP) (≤25 mmHg) at presentation were predictive of achieving a BCVA of 20/400 or better at 6-month follow-up after treatment. Initial management (TAI vs. PPV), duration of symptoms, presence of pain, presence of hypopyon, presenting BCVA, and culture status (positive vs. negative) were not found to be predictive of visual outcomes at 6-month follow-up. CONCLUSIONS: No significant difference in BCVA at 6-month follow-up was detected between the TAI and PPV groups. Younger age and lower IOP at presentation were associated with better visual outcomes at 6-month follow-up.

Management of rhegmatogenous retinal detachment with coexistent macular hole in the era of internal limiting membrane peeling.

PURPOSE: To review outcomes of vitrectomy plus or minus scleral buckling for retinal detachment (RD) attributable to peripheral break(s) with noncausal macular hole, plus or minus internal limiting membrane (ILM) peeling. DESIGN: Retrospective chart review. METHODS: Forty-nine consecutive patients from March 1, 1998 to March 31, 2009 with RD attributable to peripheral break and macular hole were treated by vitrectomy. Five had no scleral buckle placed. Forty-three underwent ILM peeling. RESULTS: The main outcome measures were retinal reattachment, macular hole status, and vision. Final retinal reattachment rate was 95.9% (47/49) with 1 and 100% with 2 operations. Final macular hole closure rate was 39/43 with ILM peeling (90.7%), and 2/6 without (33.3%, P value = .0041). Mean final acuity was 20/120, and 20/100 if the macular hole was closed. CONCLUSION: Vitrectomy, plus or minus scleral buckle, with ILM peeling is effective for repair of RD with macular hole. ILM peeling can increase the rate of macular hole closure.

Diabetic macular edema associated with glitazone use.

PURPOSE: To describe diabetic macular edema (DME) in patients who developed fluid retention as a consequence of glitazone use. METHODS: A chart review identified 30 patients who used pioglitazone or rosiglitazone and had both lower extremity edema and macular edema. Clinical reports, photographs, and fluorescein angiograms were reviewed. Patients followed for >3 months were analyzed separately. RESULTS: Seventeen patients took oral pioglitazone, 11 took rosiglitazone, and 2 took both drugs at different times. Eleven patients were observed for >3 months after cessation of glitazones. Mean weight gain during drug administration in this group was 30 lb, and mean weight loss after drug discontinuation was 19 lb. Rapid reduction in macular edema off drug occurred in only 4 of 11 patients, but 8 of 11 had reduced edema over 2 years. Mean visual acuity in this group at the initial visit was 20/60, and at the final visit, it was 20/85. Four eyes of three patients had resolution of diffuse macular edema with improved vision after cessation of glitazones without laser treatment. CONCLUSIONS: Fluid retention occurs in 5% to 15% of patients taking glitazones. In some of these patients, glitazone use appears to be a cause of macular edema, and drug cessation appears to result in rapid resolution of both peripheral and macular edema. Fluid retention associated with glitazone use should be considered when assessing treatment options for patients with DME, especially those with concomitant peripheral edema.

Extended follow-up of small melanocytic choroidal tumors treated with transpupillary thermotherapy.

OBJECTIVE: To report our longer-term follow-up observations in patients with small choroidal melanomas primarily treated with transpupillary thermotherapy (TTT). METHODS: In this noncomparative interventional case series, 40 patients with small melanocytic tumors of the choroid (thickness <3.5 mm) underwent TTT. Follow-up examinations including ophthalmoscopy, ultrasonography, and fundus photography were conducted at 24 to 48 hours, 2 to 6 weeks, and 6-month intervals after treatment. RESULTS: Forty patients (mean age, 58 years) with small melanocytic tumors underwent TTT. Mean follow-up in all patients was 42 months. In most cases TTT resulted in tumor regression. Thirty-one (77.5%) of 40 tumors did not recur after initial treatment with TTT. In 5 (12.5%) of 40 tumors with initial basal diameters ranging from 4 x 2.75 mm to 7.5 x 6 mm and a mean initial thickness of 2.0 mm, edge recurrences developed, which were satisfactorily treated with additional TTT (4 cases) or cryotherapy (1 case). The mean interval between initial TTT and recurrence in this subgroup was 15 months (range, 7-22 months). Of 36 eyes that were successfully treated with TTT or cryotherapy, 26 eyes (72%) had posttreatment visual acuity better than or equal to pretreatment visual acuity. Four (10%) of 40 tumors were not controlled with TTT and eventually required brachytherapy (n = 1), proton radiation (n = 1), or enucleation (n = 2). The initial basal diameters of these tumors ranged from 7.5 x 7.5 mm to 9 x 7.5 mm, with a mean initial thickness of 2.6 mm. The mean interval between treatment and determination of treatment failure was 22 months (range, 7-30 months). CONCLUSIONS: Transpupillary thermotherapy resulted in tumor regression of most small melanocytic choroidal tumors. Tumor edge recurrences were successfully treated with additional TTT in most cases. Four tumors required irradiation or enucleation because of treatment failures with TTT. Transpupillary thermotherapy as a stand-alone therapy is insufficient for some small choroidal melanomas.

Arteriovenous crossing dissection without separation of the retina vessels for treatment of branch retinal vein occlusion.

PURPOSE: To evaluate visual outcome after arteriovenous (AV) crossing dissection for the treatment of branch retinal vein occlusion (BRVO) and secondary macular dysfunction in which difficulty separating the retinal vessels was experienced. METHODS: A pars plana vitrectomy and dissection of the involved AV crossing site were performed consecutively in 20 eyes of 20 patients with BRVO and vision loss. The overlying retinal artery was dissected free from the retinal surface, and separation of the artery and vein at the crossing site was attempted. RESULTS: In 19 of 20 eyes, the retinal artery was dissected around the crossing site, but a marked adhesion between the artery and vein precluded separation. After a mean follow-up of 10.5 months, VA improved by at least two lines in 16 eyes (80%), remained unchanged in three eyes (10%), and worsened by at least two lines in three eyes (10%). Mean change (+/- SE) in logMAR acuity was -0.28 +/- 0.11 (two or three lines of improvement, P = 0.016) at 1 to 2 months' follow-up and -0.44 +/- 0.14 (three or four lines of improvement, P = 0.008) at the final follow-up. Cataract formation or progression occurred in 88%. CONCLUSIONS: A surgically important adhesion between the retinal artery and vein at proximal AV crossings was encountered in all eyes undergoing AV crossing dissection, correlating with previous histologic and cadaver eye studies. Cataract formation or worsening was a frequent complication. Visual improvement may occur after vitrectomy and AV crossing dissection without separation of the retinal vessels.

A family with Axenfeld-Rieger syndrome and Peters Anomaly caused by a point mutation (Phe112Ser) in the FOXC1 gene.

PURPOSE: Mutations of the forkhead transcription factor gene FOXC1 result in anterior segment anomalies. No description of the spectrum of defects resulting from a single point mutation of this gene exists in the ophthalmology literature. We have screened all available patients with Axenfeld-Rieger genes (PITX2 and FOXC1). In this report, we clinically characterize the spectrum of ocular and systemic manifestations in one family resulting from a previously reported point mutation (Phe112Ser) in FOXC1. DESIGN: Observational case series. METHODS: Ten members of a multigenerational family were examined for signs of glaucoma, anterior segment abnormalities, and systemic features of Axenfeld-Rieger syndrome. The examinations were performed in an ophthalmology examination room or in the patients' homes. Blood was obtained from 10 members and screened for mutations in FOXC1 using direct DNA sequencing. RESULTS: A single mutation causing a T to C change in codon 112 (Phe112Ser) of FOXC1 was present in six members of the family. Five of these six patients were examined and all demonstrated anterior segment anomalies. One patient had Axenfeld anomaly, one had Rieger syndrome, and one had both Axenfeld anomaly and Peters anomaly. Additionally, some members demonstrated cardiac abnormalities, which may be secondary to their FOXC1 mutation. CONCLUSIONS: A wide spectrum of clinical phenotypes can result from a single point mutation of FOXC1. This report confirms that Rieger syndrome (with dental and facial abnormalities) can be caused by a mutation in FOXC1. It is also the first report of Peters anomaly being caused by a FOXC1 mutation.