Mechanism and outcomes of recreational and sports-related open globe injuries.

OBJECTIVES: To describe the mechanisms and visual outcomes of recreational and sports-related open globe injuries (OGIs). METHODS: A retrospective case series of eyes experiencing OGI secondary to recreational and sports-related activities at Memorial Hermann Hospital - Texas Medical Center (MHH-TMC) from January 1st, 2010 through March 31st, 2015 was conducted. Exclusionary criteria included no documented ophthalmologic examination upon presentation and repairs performed by services other than ophthalmology. A two-tailed t-test and Fisher's exact test were utilized to assess for statistical significance (p < 0.05). RESULTS: A total of 20 eyes from 20 patients experiencing OGIs secondary to recreational and sports-related activities were included. Thirteen eyes (65 %) presented with OGIs from penetrating objects while seven eyes (35 %) had injuries from blunt injuries. Males comprised most of the total study group (17 of 20 patients), and zone 3 injuries were the most common location of OGI. While eyes with OGIs from blunt trauma underwent evisceration/enucleation procedures more frequently than OGIs from penetrating mechanisms (71% vs 23 %) (p = 0.10), the final visual outcomes were similarly poor between groups. Only three eyes in this series experienced an improvement from baseline VA; all three eyes had lacked initial findings consistent with severe injury. CONCLUSIONS: Recreational and sports related OGIs most commonly occur in zone 3 and in young males, regardless of injury type. OGIs due to both penetrating and blunt trauma mechanisms implicate poor functional outcomes, but the absence of certain presenting injury features may indicate possibility of eventual visual recovery.

The Use of Large Language Models to Generate Education Materials about Uveitis.

OBJECTIVE: To assess large language models in generating readable uveitis information and in improving the readability of online health information. DESIGN: Evaluation of technology. SUBJECTS: Not applicable. METHODS: ChatGPT and Bard were asked the following prompts: (prompt A) "considering that the average American reads at a 6th grade level, using the Flesch-Kincaid Grade Level (FKGL) formula, can you write patient-targeted health information on uveitis of around 6th grade level?" and (prompt B) "can you write patient-targeted health information on uveitis that is easy to understand by an average American?" Additionally, ChatGPT and Bard were asked the following prompt from the first-page results of Google when the term "uveitis" was searched: "Considering that the average American reads at a 6th grade level, using the FKGL formula, can you rewrite the following text to 6th grade level: [insert text]." The readability of each response was analyzed and compared using several metrics described below. MAIN OUTCOME MEASURES: The FKGL is a highly validated readability assessment tool that assigns a grade level to a given text, the total number of words, sentences, syllables, and complex words. Complex words were defined as those with > 2 syllables. RESULTS: ChatGPT and Bard generated responses with lower FKGL scores (i.e., easier to understand) in response to prompt A compared with prompt B. This was only significant for ChatGPT (P < 0.0001). The mean FKGL of responses to ChatGPT (6.3 ± 1.2) was significantly lower (P < 0.0001) than Bard 10.5 ± 0.8. ChatGPT responses also contained less complex words than Bard (P < 0.0001). Online health information on uveitis had a mean grade level of 11.0 ± 1.4. ChatGPT lowered the FKGL to 8.0 ± 1.0 (P < 0.0001) when asked to rewrite the content. Bard was not able to do so (mean FKGL of 11.1 ± 1.6). CONCLUSIONS: ChatGPT can aid clinicians in producing easier-to-understand health information on uveitis for patients compared with already-existing content. It can also help with reducing the difficulty of the language used for uveitis health information targeted for patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Postoperative Complications of True Dropless Cataract Surgery versus Standard Topical Drops.

Purpose Compare postoperative outcomes in cataract surgery between eyes with standard drop regimen versus dropless protocol by residents. Design Retrospective cohort study between April 1, 2018 and March 31, 2020. Methods The study was performed at Lyndon B. Johnson General Hospital in Houston, Harris County, Texas. A total of 547 eyes (234 dropless vs. 313 standard) with phacoemulsification cataract surgery and minimum of 1-month follow-up with best-corrected visual acuity (BCVA) were included. Dropless received 40 mg sub-Tenon's triamcinolone and intracameral moxifloxacin. Patients were followed at postoperative day 1 (POD1), week 1 (POW1), and month 1 (POM1). Postoperative rate of BCVA better than 20/40 (Good vision) and rate of complications were compared between groups. Results Good vision on POM1 in dropless (77.8%) was noninferior to standard (75.1%, p = 0.80). Complication rate in dropless (28.6%) was noninferior to standard (24.0%, p = 0.13). Intraocular pressure (IOP) elevation on POD1 ( p = 0.041) and anterior chamber (AC) cells on POW1 and POM1 ( p < 0.001) were more frequent in dropless. Mean spherical equivalent at POM1 was better in dropless (-0.37 D [±0.81 D]) compared with standard (-0.61D [±0.77 D], p = 0.001). Early posterior capsular opacification (early PCO) was more frequent in dropless ( p = 0.042). Conclusions Postoperative rate of BCVA better than 20/40 and rate of postoperative complications were noninferior, although dropless had higher rates of AC inflammation, IOP elevation, and early PCO.

Ophthalmic manifestations of tuberculosis.

PURPOSE OF REVIEW: To evaluate the epidemiology, microbiology, and pathology of Mycobacterium Tuberculosis (MTB). Utilizing these basic science concepts, the reader will discover how MTB can cause disease in any part of ophthalmic system. This article will aid clinicians in establishing the difficult diagnosis and management strategies for ophthalmic tuberculosis (OTB). RECENT FINDINGS: Recently, expert panels have reached a consensus on naming conventions and treatment strategies for the variety of ocular tuberculosis (TB). This consensus helps individual clinicians decide when to recommend full anti-TB treatment. SUMMARY: Globally, TB is nearly ubiquitous in the human population. It is most recognized for its pulmonary disease, but pathology of nearly every structure of the ophthalmic system has been identified. This heterogeneity makes establishing a diagnosis difficult, but recent improvements in expert panel naming consensus and nucleic acid amplification tests are improving diagnostic abilities. Clinicians are now feeling more confident with prescribing anti-TB regimens, but ongoing questions regarding the use of oral steroids and risk of medication-induced ocular toxicity remain.

Case series: Traumatic ocular lacerations secondary to pressure washers.

Purpose: Numerous causes of ocular lacerations, including, open globe injuries have been extensively reported but to our knowledge this is first time that pressure washers have been reported to be the culprit. Thus, in this case series we describe the uniqueness of ocular findings secondary to high-power pressure washer injuries that are a result of their mechanistic function. Observations: Here we report a case series of 3 patients who presented in an emergency department with pain and decreased visual acuity following usage of high-pressure washer machines. All three patients presented with features of both blunt and sharp mechanisms of ocular injury. Most lacerations caused injury that encompassed more than one zone. Two of the patients experienced an open globe injury, and all patients had poor final visual outcomes. Extraocular involvement included fractures and lid lacerations. All patients were managed surgically with repair of the ocular defects. Visual outcome in the first patient was hand motion, while the second patient received a prosthesis following enucleation due to lack of recovery after four months. Lastly, we were unable able to obtain visual outcome for the third patient due to lack of follow up. Conclusion: Ocular injuries due to pressure washers have not been reported in literature, however, this case series serves to elucidate that pressure washers can cause ocular injuries with both blunt and laceration mechanical effects. Moreover, special care should be taken in preventing and managing these injuries due to their high ocular morbidity.

Readability and Suitability of Online Patient Education Materials for Glaucoma.

PURPOSE: To assess the quality, content, readability, and accountability of information about glaucoma found online. DESIGN: Cross-sectional study. PARTICIPANTS: Thirteen websites containing patient education materials for glaucoma were analyzed in this study. METHODS: An online Google search was conducted using the keyword "glaucoma." Thirteen medical website results were selected for analysis. Each website was assessed by 3 independent reviewers for suitability, readability, and accountability. The standardized Suitability Assessment of Materials (SAM) tool was used to evaluate the quality and content of information on each website. The Flesch Reading Ease (FRE) score, Flesch-Kincaid Grade Level (FKGL), Coleman-Liau Index (CLI), Simple Measure of Gobbledygook (SMOG) index, Automated Readability Index (ARI), and Linsear Write Formula (LWF) score were used to assess the readability of the websites. The Journal of the American Medical Association (JAMA) accountability benchmarks were used to evaluate each website's accountability. MAIN OUTCOME MEASURES: These included SAM, FRE, FKGL, CLI, SMOG index, ARI, and LWF scores as well as JAMA accountability benchmarks. RESULTS: The average SAM score for all the websites included in this study was 18 points out of a possible 34 points. Eyewiki.org was the lowest-scoring website (11.7 ± 0.6 points), whereas aao.org and nei.nih.gov were the highest-scoring websites (26.0 ± 1.0 points and 26.0 ± 2.6 points, respectively). Three content graders in this study were in moderate agreement (kappa statistic = 0.50). The average FRE score among all the websites was 47.0 (95% confidence interval [CI], 39.3-54.7). The average reading grade score among all the websites was 11.2 (95% CI, 10.0-12.4). Two of the 13 websites (15.4%) satisfied all 4 JAMA accountability criteria. CONCLUSIONS: There is significant variation in the content and quality of freely available, online glaucoma education material. The material is generally either not suitable or only adequate for use. Most websites reviewed are written at a reading grade level higher than that recommended for patient education materials.

Treatment Outcomes in Birdshot Chorioretinitis: Corticosteroid Sparing, Corticosteroid Discontinuation, Remission, and Relapse.

PURPOSE: To describe treatment-related outcomes among patients with birdshot chorioretinitis (BSCR). DESIGN: Retrospective cohort study. PARTICIPANTS: Patients diagnosed with BSCR at 2 tertiary care academic medical centers. METHODS: Clinical and treatment-related data were collected for all patients with BSCR diagnosed between 2003 and 2017 at the 2 centers and for each eye at each clinical visit. MAIN OUTCOME MEASURES: Four outcomes were considered: (1) corticosteroid-sparing success, defined as inactive disease and prednisone dose of ≤7.5 mg/day; (2) corticosteroid-discontinuation success, defined as inactive disease and discontinuation of prednisone; (3) sustained drug-free remission, defined as inactive disease off all medications for ≥3 months; and (4) relapse of BSCR after remission. RESULTS: A total of 107 patients with BSCR were identified, of whom 94 had follow-up data. Corticosteroid-sparing success was achieved in 95.4% of the oral corticosteroid-treated patients at a rate of 0.60 successes per person-year (PY) (95% CI: 0.50/PY, 0.70/PY). The median time to corticosteroid-sparing success was 12 months. Corticosteroids were discontinued successfully in 76.5% of oral corticosteroid-treated patients (rate = 0.28/PY; 95% CI: 0.21/PY, 0.35/PY). The median time to successful corticosteroid discontinuation was 2.0 years. A sustained drug-free remission was achieved in 24 patients (rate = 0.06/PY; 95% CI: 0.04/PY, 0.09/PY), with approximately 25% of patients achieving remission by 4 years of follow-up. Relapse of inflammation in patients after achieving a sustained, drug-free remission occurred at a rate of 0.24/PY (95% CI: 0.14/PY, 0.37/PY). CONCLUSIONS: Successful corticosteroid sparing and discontinuation was achieved in the majority of patients with BSCR. Remission occurred less often, but data were limited by the time needed to induce a remission (4 years) and the amount of follow-up (median, 4.6 years). The relapse rate after a remission was 0.24/PY.

Current Landscape of Uveitis Specialists in the United States.

Purpose This study characterizes the current landscape of uveitis specialists and their practice settings in the United States. Methods An anonymous Internet-based survey with questions pertaining to training history and practice characteristics was distributed via REDCap to the American Uveitis Society and Young Uveitis Specialists listservs. Results Forty-eight uveitis specialists in the United States responded to the survey out of 174 uveitis specialists that identify as practicing in the United States. Twenty-five of 48 respondents (52%) completed an additional fellowship. These additional fellowships ranged from surgical retina (12/25, 48%), cornea (8/25, 32%), and medical retina (4/25, 16%). Two-thirds of uveitis specialists managed their own immunosuppression, while one-third comanaged immunosuppression with rheumatologists. Thirty-three of 48 (69%) maintained a surgical practice. Conclusion This is the first survey of uveitis specialists across the United States to provide understanding into training and practice characteristics. These data will provide insight into career planning, practice building, and assist in resource allocation.

Non-traumatic open globe injuries: presenting characteristics and visual outcomes.

PURPOSE: To describe clinical characteristics and visual outcomes of non-traumatic open globe injuries. SETTING: A level 1 trauma centre in a large urban medical centre. DESIGN: Retrospective study. METHODS: Charts of non-traumatic open globe patients admitted to MHH-TMC from 1/2010 to 3/2015 were reviewed for demographics, cause, clinical characteristics, visual acuity (VA) and enucleation. RESULTS: Thirty eyes were included: 15 (50%) were males with a mean age of 47 (±28) years. All presented with zone 1 injury. Twenty-five (83%) had a perforated corneal ulcer. Presenting VA was count fingers (n = 3, 10%) to NLP (n = 6, 20%). Twenty-four (80%) involved infection, 5 (17%) congenital, 3 (10%) chemical burn and 2 (7%) neurotrophic. Conjunctival injection (n = 22, 77%), corneal opacification (n = 20, 71%) and relative afferent pupillary defect (n = 9, 44%) were common. After treatment, 23 (88%) were worse than 6/60 (20/200), 9 (35%) were NLP and 8 (27%) required enucleation. CONCLUSIONS: Often non-traumatic open globe injuries are zone 1 and due to perforated infectious ulcers. Compared to previously reported traumatic injuries, these have higher rates of enucleation (27% vs 8%) and poorer final VA (88% vs 68% worse than 6/60 20/200).

Determining Risk Factors That Affect Progression in Patients with Nonproliferative Diabetic Retinopathy.

PURPOSE: To determine risk factors that affect nonproliferative diabetic retinopathy (NPDR) progression and establish a predictive model to estimate the probability of and time to progression in NPDR. Patients and Methods. Charts of diabetic patients who received an initial eye exam between 2010 and 2017 at our county hospital were included. Patients with proliferative diabetic retinopathy (PDR), fewer than 2 years of follow-up, or fewer than 3 clinic visits were excluded. Demographics and baseline systemic and ocular characteristics were recorded. Follow-up mean annual HbA1c and blood pressure, best-corrected visual acuity, and the number of antivascular endothelial growth factor treatments were recorded. Stage and date of progression were recorded. A 5-state nonhomogeneous continuous-time Markov chain with a backward elimination model was used to identify risk factors and estimate their effects on progression. RESULTS: Two hundred thirty patients were included. Initially, 65 eyes (28.3%) had no retinopathy; 73 (31.7%) mild NPDR; 60 (26.1%) moderate NPDR; and 32 (13.9%) severe NPDR. Patients were followed for a mean of 5.8 years (±2.0 years; range 2.1-9.4 years). 164 (71.3%) eyes progressed during the follow-up. Time-independent risk factors affecting progression rate were age (hazard ratio (HR) = 0.99, P=0.047), duration of diabetes (HR = 1.02, P=0.018), and Hispanic ethnicity (HR = 1.31, P=0.068). Mean sojourn times at mean age, duration of diabetes, and annual HbA1c for a non-Hispanic patient were estimated to be 3.03 (±0.97), 4.63 (±1.21), 6.18 (±1.45), and 4.85 (±1.25) years for no retinopathy, mild NPDR, moderate NPDR, and severe NPDR, respectively. Each 1% increase in HbA1c annually diminished sojourn times by 15%, 10%, 7%, and 10% for no retinopathy, mild NPDR, moderate NPDR, and severe NPDR, respectively. CONCLUSION: HbA1c level is a significant modifiable risk factor in controlling the progression of DR. The proposed model could be used to predict the time and rate of progression based on an individual's risk factors. A prospective multicenter study should be conducted to further validate our model.

Using Anterior Segment Optical Coherence Tomography (ASOCT) Parameters to Determine Pupillary Block Versus Plateau Iris Configuration.

PRéCIS:: The potential parameters for differentiating pupillary block (PB) from plateau iris configuration (PIC) on anterior segment optical coherence tomography (ASOCT) are lens/pupil size parameters and angles. Further study is needed to determine a landmark peripheral to the centroid of the iris. PURPOSE: Investigate anterior segment parameters to distinguish between 2 mechanisms of angle closure, PB and PIC, using swept-source Fourier domain ASOCT. PATIENTS AND METHODS: Retrospective ASOCT images from narrow angle eyes were reviewed. PIC was defined either by ultrasound biomicroscopy and/or clinically when an iridoplasty was performed. Images were read by a masked reader using Anterior Chamber Analysis and Interpretation software to identify scleral spur landmarks and calculate anterior chamber, peripheral angle, iris size, iris shape, and lens/pupil size parameters. ASOCT parameters were summarized and compared using the 2-sample t test. Thresholds and area under receiver operating characteristic curve were calculated using logistic regression analysis. RESULTS: One hundred eyes (66 PB and 34 PIC) of 100 participants were reviewed. Of all ASOCT parameters, iris length in each quadrant, pupil arc, lens/pupil parameters (pupil arc, lens vault, and pupil diameter), all pupillary margin-center point-scleral spur landmark (PM-C-SSL) parameters, and all except superior central iris vault parameters were significantly different between PB and PIC. On threshold evaluation, lens/pupil parameters had the greatest area under receiver operating characteristic curve values (0.77 to 0.80), followed by PM-C-SSL angles (0.71 to 0.75). CONCLUSIONS: We propose that the pupil size parameters and PM-C-SSL angle are the most reliable novel ASOCT parameters to distinguish between PB and PIC eyes. These parameters do not rely on the visibility of the posterior iris surface, which is difficult to identify with ASOCT, but may be ambient lighting dependent.

Alexandrite laser induced uveitis & pigment dispersion: A case report and review of the literature.

PURPOSE: To describe a complication of an upper eyelid alexandrite laser procedure. OBSERVATIONS: A 55-year-old woman presented with left eye blurred vision and photophobia after a left upper eyelid procedure with an alexandrite laser. She had elevated intraocular pressure (IOP), anterior chamber cell and pigment, posterior synechiae, and retroillumination defects in the left eye. She was treated with topical prednisolone and brimonidine. Six months later, although her anterior chamber had cleared and IOP had normalized, the patient reported decreased vision-related quality of life from persistent photophobia. CONCLUSIONS AND IMPORTANCE: Alexandrite lasers are commonly used for hair removal and skin depigmentation. When used periocularly without proper eye protection, they have the potential to create irreversible ocular complications. This case demonstrates the importance of proper eye protection with periocular laser procedures.

Burkitt lymphoma masquerading as Tolosa-Hunt syndrome in an HIV-seropositive patient.

PURPOSE: To describe a rare case of Burkitt lymphoma metastatic to the cavernous sinus that was initially diagnosed as Tolosa-Hunt syndrome. CASE DESCRIPTION: A 31-year-old confirmed and treatment-compliant HIV-positive Hispanic male acutely developed diplopia, ptosis, numbness in the V1 distribution, and complete external ophthalmoplegia in the right eye over 1 week. Imaging showed a mass-like lesion within the right cavernous sinus without other intracranial abnormalities. He was started on broad-spectrum antibiotics and antifungals without improvement. Inflammatory and infectious workup was negative. A presumed diagnosis of Tolosa-Hunt syndrome was made based on clinical and radiographic findings, as well as the absence of another etiology to explain the patient's presentation. He was then started on high-dose oral steroids with improvement of orbital pain only. Shortly after being discharged on steroids, the patient returned to the hospital with severe abdominal pain. Computed tomography of the abdomen showed perforated ileitis with aneurysmal dilation of the ileum and marked wall thickening concerning for a mass lesion. Positron emission tomography-computed tomography showed an uptake in the terminal ileum and right cavernous sinus consistent with metastatic Burkitt lymphoma, matching with pathology. After several cycles of chemotherapy, symptoms improved, and he regained full ocular motility in the affected eye. However, the patient ultimately died due to peritonitis and pyelonephritis. CONCLUSION: Burkitt lymphoma metastatic to the cavernous sinus was diagnosed after an initial diagnosis of Tolosa-Hunt syndrome. Tolosa-Hunt syndrome is a diagnosis of exclusion and should only be made after ruling out other pathologies.

Repositioning a posteriorly dislocated silicone plate-haptic toric intraocular lens.

We describe a technique for repositioning an encapsulated, posteriorly dislocated silicone plate-haptic toric intraocular lens (IOL) while preventing further dislocation into the vitreous cavity. Sutures of 10-0 polypropylene were used to ensure safe retrieval of the dislocated IOL. An anterior vitrectomy was then performed to remove the contracted capsular bag around the IOL. The IOL fixation hole was temporarily externalized to allow quick and secure IOL fixation, eliminating the risk for losing the slippery silicone IOL into the vitreous cavity. Using this technique, the IOL was successfully placed in the proper position and resulted in good vision for the patient while avoiding the trauma of lens exchange.

Idiopathic Central Nervous System Inflammatory Disease in the Setting of HLA-B27 Uveitis.

Purpose: The purpose of the article is to describe a novel case of idiopathic central nervous system inflammatory disease with bilateral human leukocyte antigen (HLA)-B27-positive anterior uveitis. Methods/Results: A 15-year-old African American boy with bilateral HLA-B27-positive anterior uveitis controlled with topical and oral steroids for 8 months acutely developed headaches, left eyelid ptosis, and binocular diplopia. Imaging showed lesions in the right midbrain, superior colliculus, cerebellar peduncles, and cerebellar vermis and leptomeningeal enhancement along the vermian foliae. Cerebral spinal fluid tests showed mild lymphohistiocytic pleocytosis with negative cytology; inflammatory and infectious workup were negative. He received intravenous methylprednisolone without initial symptomatic improvement; repeat magnetic resonance imaging (MRI) showed reduced lesion burden. Oral steroids were continued; his symptoms resolved in 1 month. Repeat MRI 2 months after presentation showed almost complete lesion resolution. Conclusions: Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) was diagnosed. HLA-B27 positivity may represent a novel association with CLIPPERS.