RetINal Toxicity And HydroxyChloroquine Therapy (INTACT): protocol for a prospective population-based cohort study.

PURPOSE: Hydroxychloroquine (HCQ) is an important medication for patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and other rheumatic diseases. Although it is well-tolerated and cost-effective, the risk of HCQ retinal toxicity is of increasing concern. The aim of this study is to re-examine the HCQ retinal toxicity incidence rate, risk factors and clinical course after discontinuation. METHODS: We designed a prospective population-based cohort study in adult patients with SLE or RA, currently receiving HCQ for five or more years, who are residents of British Columbia (BC), Canada. Based on administrative data, we identified 5508 eligible participants (1346 SLE and 4162 RA). They will participate in annual or biannual retinal screening over 5 years in alignment with the recently revised American Academy of Ophthalmology guidelines. To standardise procedures for retinal screening, imaging, diagnostic criteria, severity staging and data transfer, a consensus meeting was convened in December 2019 with participation of BC retinal specialists and the research team. Agreement was attained on: use of spectral domain-optical coherence tomography as the primary objective screening modality; classification of images into categories of normal, equivocal or abnormal; and transferring the equivocal and abnormal images plus corresponding subjective test results via cloud-based server from each clinic to a reading centre. Confirmation of HCQ retinal toxicity diagnoses and severity staging will be performed by three independent and masked reviewers. The incidence of HCQ retinal toxicity will be calculated, accounting for the competing risk of death. Hazard ratios for each risk factor will be calculated for the risk of HCQ retinopathy, after adjusting for confounders. We will also estimate the risk of HCQ retinal toxicity progression over 5 years. ETHICS AND DISSEMINATION: This study has received approval from the University of British Columbia Clinical Research Ethics Board (H20-00736) and the Vancouver Coastal Health Research Institute.

Early Pars Plana Vitrectomy for Treatment of Acute Infective Endophthalmitis.

PURPOSE: To evaluate the efficacy and safety of early pars plana vitrectomy (PPV) for the treatment of acute infective endophthalmitis, and identify prognostic factors for better visual outcome. DESIGN: Retrospective cohort study. METHODS: Consecutive patients who underwent early PPV within 72 hours of presentation for the treatment of acute infective bacterial endophthalmitis and presented to a large tertiary referral center in New South Wales, Australia, between January 2009 and December 2013 were included. Changes in best-corrected visual acuity (VA) from baseline to 1 year were examined. RESULTS: A total of 64 patients were included. The inciting events were cataract surgery (53%), intravitreal injection (36%), trabeculectomy (3%), and endogenous (3%). The mean VA improved from 3.1 logMAR (hand motion) at baseline to 1.02 (approximately 20/200) at 1 year, with 42% achieving final VA equal to or better than 0.477 logMAR (20/60) following early PPV. Positive prognostic factors were negative microbial cultures (P < 0.01) and etiology of post-cataract surgery (P < 0.01). In multivariable analyses adjusting for age and prognostic factors, patients with baseline VA of light perception and hand motion achieved greater visual gains than those with counting fingers, with gains of logMAR of -2.68, -2.09, and -0.85, respectively (P < 0.0001). CONCLUSIONS: Most patients who undergo early PPV experience substantial VA improvement. Negative microbial cultures and endophthalmitis after cataract surgery were associated with better final visual outcome. Patients with presenting VA of light perception or hand motion achieved higher visual gains than those with counting fingers, suggesting the possibility that early PPV may be beneficial in both groups.

The corneal ulcer one-touch study: a simplified microbiological specimen collection method.

PURPOSE: To determine if a new, single-sample device (ESwab; Copan Diagnostics, Inc) can simplify the traditional multi-sample approach to specimen collection in infectious keratitis. DESIGN: Prospective, diagnostic test evaluation. METHODS: In this institutional study, patients with suspected infectious keratitis meeting traditional criteria for diagnostic corneal specimen collection and culture were randomized to the order of first specimen collection method: ESwab or a sample directly plated for growth on chocolate agar. This was followed by standard samples for blood agar, Gram stain, Sabouraud agar, thioglycolate broth, and brain heart infusion broth in all cases. The specimens collected using the 2 approaches were analyzed separately by the laboratory in a masked fashion. The main outcome measure was positive growth on cultured media. RESULTS: Eighty-one eyes from 80 consecutive patients were sampled. Culture positivity rate for the multi-sample method and ESwab was 70% and 69%, respectively, with a 75% agreement rate. ESwab sensitivity was 84% (95% confidence interval [CI]: 72%-93%), with a specificity of 67% (95% CI: 45%-84%). Positive and negative predictive values of the ESwab were 86% (95% CI: 74%-94%) and 64% (95% CI: 43%-82%), respectively. There was no difference in positive culture reports with respect to the order of specimen collection technique used. CONCLUSIONS: The single-sample ESwab method is a more accessible and less cumbersome approach to corneal culturing for ophthalmologists, particularly those in the community setting who do not have access to the full set of traditional culture materials. Culture results using this single-sample approach were comparable to the multi-sample method.

Travel to high mountain elevations following vitrectomy with intraocular gas.

PURPOSE: To evaluate the effects and safety of travel by land through high mountainous elevations after surgery in patients who have undergone pars plana vitrectomy with intraocular gas. METHODS: A retrospective cohort study of 75 patients post pars plana vitrectomy with intraocular gas who traveled by land through mountain elevations of up to 3895 feet above sea level within 1 day of surgery. RESULTS: The average rate of ascent through the mountains was 29 ft/min and the maximum theoretical ocular compensation was 0.57 cubic centimeters (cc), which occurred at 4259 feet above sea level. A statistically significant change in postoperative intraocular pressure was found when compared with preoperative (P = 0.010), with two factors influencing this change: the type of gas (C3F8, P = 0.038) and lens status (pseudophakic, P = 0.010), with a mean final intraocular pressure still within the safe range. There were no cases of retinal vascular occlusion, acute elevations of intraocular pressure requiring surgical intervention, or symptomatic visual field loss attributable to elevated intraocular pressure. CONCLUSION: It seems that patients with a complete fill of intraocular gas after pars plana vitrectomy may travel safely by land through mountains with a peak ascent of 3895 feet, final ascent of 2787 feet, and a mean rate of 29 ft/min. These findings can significantly impact patient costs and convenience.

Vitreoretinal lymphoma: a 20-year review of incidence, clinical and cytologic features, treatment, and outcomes.

OBJECTIVES: To determine the incidence and clinical and cytologic diagnostic accuracy of vitreoretinal lymphoma (VRL) and to evaluate its clinical features, management, and outcomes in a cohort of patients who underwent diagnostic vitrectomy. METHODS: Retrospective medical record review of 463 diagnostic vitrectomy specimens from 430 patients collected from October 1, 1990, through December 31, 2010, from Vancouver General Hospital and the British Columbia Cancer Agency. RESULTS: A total of 22 patients were diagnosed as having VRL with a preoperative clinical diagnostic sensitivity of 77%, specificity of 73%, positive predictive value of 13%, and negative predictive value of 98%. The cytologic diagnostic sensitivity was 87% (27 of 31 specimens). The incidence of VRL in British Columbia doubled from 1990 to 2010, with a final incidence of 0.047 cases per 100 000 people per year. The mean age at diagnosis was 66 years. Seventeen patients (77%) were women. The initial diagnosis of lymphoma was VRL in 19 patients (86%), of whom 7 (37%) had concurrent central nervous system lymphoma. Recurrent disease was found in 11 patients. Large B-cell lymphoma was diagnosed in 20 patients (91%). The median progression-free survival was 11 months, and the median survival was 33 months from the initial diagnosis. CONCLUSIONS: Vitreoretinal lymphoma remains a clinical diagnostic challenge. Early clinical suspicion with subsequent diagnostic vitrectomy for cytologic analysis and collaboration with the oncology department is critical to appropriate and prompt staging and treatment. More interdisciplinary studies are required to further characterize VRL and maximize the therapeutic options, thus improving the morbidity and mortality associated with the disease.

High-density silicone oil Densiron-68 as an intraocular tamponade for primary inferior retinal detachments.

PURPOSE: To evaluate the effectiveness and safety of the heavy silicone oil Densiron-68 as an internal retinal tamponade after vitrectomy in patients with primary inferior rhegmatogenous retinal detachment. METHODS: A retrospective consecutive case series involving inferior rhegmatogenous retinal detachment in 42 patients recruited between 2007 and 2010 was completed. All patients underwent primary vitrectomy followed by injection of Densiron-68. Each patient was then examined at 1 week, 1 month, 3 months, and 6 months after its removal. Included patients had a rhegmatogenous retinal detachment with at least 1 retinal break between 4 and 8 clock hours and completed 6 months of follow-up after removal of Densiron-68. Assessments for reattachment of the retina, visual acuity, and any complications from the surgery were recorded. RESULTS: Thirty-nine of 42 patients completed all follow-up visits. Anatomical success was achieved in 85% (33 of 39) of cases with one procedure, increasing to 95% (37 of 39) with additional surgery. The mean visual acuity improved from mean logarithm of the minimum angle of resolution of 1.29 ± 0.61 preoperatively to 0.87 ± 0.67 postoperatively. The most common complications were cataracts (83%, 10 of 12), posterior capsular opacification (22%, 6 of 27), and ocular hypertension (15%, 6 of 39). CONCLUSION: High anatomical success rates can be achieved with primary vitrectomy for inferior rhegmatogenous retinal detachment with the use of Densiron-68.

All-trans retinoic Acid differentiation syndrome chorioretinopathy: a case of multifocal serous neurosensory detachments in a patient with acute promyelocytic leukemia treated with all-trans retinoic Acid.

PURPOSE: The purpose of this study was to report a case of multifocal serous neurosensory retinal detachments associated with systemic differentiation syndrome (DS) (formerly known as all-trans retinoic acid [ATRA] syndrome) in a patient with acute promyelocytic leukemia. METHODS: In this observational case report, we identify a case of DS because of ATRA induction therapy with associated multiple focal serous neurosensory retinal detachments in a 39-year-old man with acute promyelocytic leukemia. RESULTS: While suffering from a rebound episode of DS secondary to ATRA therapy, the patient experienced deterioration of his vision bilaterally. Within 8 days of discontinuing ATRA and the initiation of dexamethasone, the patient's systemic status and ocular findings resolved completely. Optical coherence tomography and fluorescein angiography confirmed the resolution of the subretinal fluid. CONCLUSION: Given the time of onset of the patient's visual symptoms with associated chorioretinopathy, his concurrent systemic manifestations of DS, along with his concurrent systemic, and ocular response to treatment, we speculate that this is the first reported occurrence of ATRA-associated chorioretinopathy in a patient with ATRA DS.