Impact of Patient Race/Ethnicity on Premium Intraocular Lens Utilization.

OBJECTIVE: To evaluate the relationship between social determinants of health and the likelihood of receiving a premium intraocular lens (IOL) at the time of cataract surgery. METHODS: Retrospective chart review of a single-center, academic ophthalmology practice over a one-year period, with a primary outcome measure of placement of either a premium or standard IOL. We used logistic regression to calculate the odds of receiving a premium IOL, stratifying patients based on self-identified race/ethnicity, age, sex, insurance type (private insurance vs. Medicare or Medicaid), estimated household income (based on median household income for zip code), and presence of ocular pathology. RESULTS: Compared with self-identified White patients, Black patients were least likely to receive premium IOLs (OR=0.220, 95% CI 0.137-0.340, P<0.001), followed by Hispanic patients (OR=0.308, 95% CI 0.104-0.730) and Asian patients (OR=0.479, 95% CI 0.302-0.734). Patients with Medicare or Medicaid insurance were also less likely to receive premium IOLs (OR 0.522, 95% CI 0.336-0.784). CONCLUSIONS: White patients in our practice were more likely to receive premium IOLs than non-White patients, even when controlling for age, sex, insurance type, estimated median household income, and presence of ocular comorbidities. The underlying reason for this disparity should be explored further.

Novel severe oculocutaneous manifestations of human monkeypox virus infection and their historical analogues.

WHO has declared human mpox (formerly known as monkeypox) a global public health emergency since July, 2022. When case numbers were increasing, so did clinicians' exposures to new elements of the disease. Additionally, the burden of mpox is particularly apparent in immunocompromised patients, who can have more variable and severe manifestations of disease across organ systems. In this Grand Round, we report novel and severe oculocutaneous manifestations of mpox in this population, which are both sight and life threatening. Specifically, we highlight two patients with mpox and AIDS who had refractory skin necrosis that progressed to either ocular compromise or panfacial gangrene, or both. Both patients ultimately died due to systemic complications of their infections. Through clinical analogies, we show how past experiences with related orthopoxviruses, such as variola virus (smallpox) and vaccinia virus, can add useful context for understanding and treating these new disease states. We suspect that in patients who are immunocompromised, monkeypox virus can clinically evolve not only via viraemia but also through direct intradermal spread. We propose that intradermal spread occurs by a process clinically and immunologically analogous to progressive vaccinia, a complication previously seen after conventional smallpox vaccination. We share evidence in support of this theory and implications regarding early management and post-exposure prophylaxis for at-risk populations. Content note: this Grand Round contains graphic images of mpox lesions of the eyes and face.

Archetypal analysis of visual fields in optic neuritis reveals functional biomarkers associated with outcome and treatment response.

BACKGROUND AND OBJECTIVES: Archetypal analysis (AA), a form of unsupervised machine learning, can identify quantifiable visual field (VF) patterns seen in optic neuritis (ON), known as archetypes (ATs). We hypothesized that AT weight changes over time would reflect the course of recovery and the effects of therapy in ON. We explored whether baseline AT weights would be associated with VF status at the clinical trial outcome and if ATs would indicate residual VF defects in eyes with mean deviation (MD) ≥ -2.00 at six months. METHODS: We used a published 16-AT model derived from 3892 Optic Neuritis Treatment Trial VFs (456 eyes) for all analyses. We measured AT weight changes over the six-month study period and used asymptotic regression to analyze the rate of change. We compared AT weights at six months between treatment groups. We evaluated associations between baseline AT weight thresholds and VF outcome or treatment effect. We calculated residual AT weights in eyes with MD ≥ -2.00 dB at six months. RESULTS: Over six months, AT1 (a normal VF pattern) demonstrated the greatest median weight change, increasing from 0.00% (IQR 0.00-0.00%) at baseline to 60.0% (IQR 38.3-70.8%) at six months (p < 0.001). At outcome, the intravenous methylprednisolone (IVMP) group had the highest median AT1 weight (IVMP: 63.3%, IQR 51.3-72.8%; placebo: 56.2%, IQR 35.1-71.6%; prednisone 58.3%, IQR 35.1-71.6%; p = 0.019). Eyes with AT1 weight ≥ 19% at baseline had superior median MD values (-0.91 vs. -2.07 dB, p < 0.001) and AT1 weights (70.8% vs. 57.8% p < 0.001) at six months. Only eyes with AT1 weight < 19% at baseline showed a treatment benefit for IVMP, with a higher six-month median AT1 weight compared to placebo (p = 0.015) and prednisone (p = 0.016), and a higher median MD compared to placebo (p = 0.027). At six months, 182 (80.2%) VFs with MD ≥ -2.00 had at least one abnormal AT. DISCUSSION: Changes in quantifiable, archetypal patterns of VF loss reflect recovery in ON. Machine learning analysis of the VFs in optic neuritis reveals associations with response to therapy and VF outcome, and uncovers residual deficits, not readily seen with standard evaluations.

Unsupervised Machine Learning Shows Change in Visual Field Loss in the Idiopathic Intracranial Hypertension Treatment Trial.

PURPOSE: We previously reported that archetypal analysis (AA), a type of unsupervised machine learning, identified and quantified patterns of visual field (VF) loss in idiopathic intracranial hypertension (IIH), referred to as archetypes (ATs). We assessed whether AT weight changes over time are consistent with changes in conventional global indices, whether visual outcome or treatment effects are associated with select AT, and whether AA reveals residual VF defects in eyes deemed normal after treatment. DESIGN: Analysis of data collected from a randomized controlled trial. PARTICIPANTS: Two thousand eight hundred sixty-two VFs obtained from 165 participants during the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT). METHODS: We applied a 14-AT model derived from IIHTT VFs. We examined changes in individual AT weights over time for all study eyes and evaluated differences between treatment groups. We created an AT change score to assess overall VF change from baseline. We tested threshold baseline AT weights for association with VF outcome and treatment effect at 6 months. We determined the abnormal ATs with meaningful weight at outcome for VFs with a mean deviation (MD) of -2.00 dB or more. MAIN OUTCOME MEASURES: Individual AT weighting coefficients and MD. RESULTS: Archetype 1 (a normal VF pattern) showed the greatest weight change for all study eyes, increasing from 11.9% (interquartile range [IQR], 0.44%-24.1%) at baseline to 31.2% (IQR, 16.0%-45.5%) at outcome (P < 0.001). Archetype 1 weight change (r = 0.795; P < 0.001) and a global score of AT change (r = 0.988; P < 0.001) correlated strongly with MD change. Study eyes with baseline AT2 (a mild diffuse VF loss pattern) weight of 44% or more (≥ 1 standard deviation more than the mean) showed higher AT2 weights at outcome than those with AT2 weight of < 44% at baseline (P < 0.001). Only the latter group showed a significant acetazolamide treatment effect. Archetypal analysis revealed residual VF loss patterns, most frequently representing mild diffuse loss and an enlarged blind spot in 64 of 66 study eyes with MD of -2.00 dB or more at outcome. CONCLUSIONS: Archetypal analysis provides a quantitative approach to monitoring VF changes in IIH. Baseline AT features may be associated with treatment response and VF outcome. Archetypal analysis uncovers residual VF defects not otherwise revealed by MD.

Archetypal Analysis Reveals Quantifiable Patterns of Visual Field Loss in Optic Neuritis.

Purpose: Identifying and monitoring visual field (VF) defects due to optic neuritis (ON) relies on qualitative clinician interpretation. Archetypal analysis (AA), a form of unsupervised machine learning, is used to quantify VF defects in glaucoma. We hypothesized that AA can identify quantifiable, ON-specific patterns (as archetypes [ATs]) of VF loss that resemble known ON VF defects. Methods: We applied AA to a dataset of 3892 VFs prospectively collected from 456 eyes in the Optic Neuritis Treatment Trial (ONTT), and decomposed each VF into component ATs (total weight = 100%). AA of 568 VFs from 61 control eyes was used to define a minimum meaningful (≤7%) AT weight and weight change. We correlated baseline ON AT weights with global VF indices, visual acuity, and contrast sensitivity. For eyes with a dominant AT (weight ≥50%), we compared the ONTT VF classification with the AT pattern. Results: AA generated a set of 16 ATs containing patterns seen in the ONTT. These were distinct from control ATs. Baseline study eye VFs were decomposed into 2.9 ± 1.5 ATs. AT2, a global dysfunction pattern, had the highest mean weight at baseline (36%; 95% confidence interval, 33%-40%), and showed the strongest correlation with MD (r = -0.91; P < 0.001), visual acuity (r = 0.70; P < 0.001), and contrast sensitivity (r = -0.77; P < 0.001). Of 191 baseline VFs with a dominant AT, 81% matched the descriptive classifications. Conclusions: AA identifies and quantifies archetypal, ON-specific patterns of VF loss. Translational Relevance: AA is a quantitative, objective method for demonstrating and monitoring change in regional VF deficits in ON.

Underutilization of advanced presurgical studies and high rates of vagus nerve stimulation for drug-resistant epilepsy: a single-center experience and recommendations.

INTRODUCTION: Epilepsy surgery continues to be profoundly underutilized despite its safety and effectiveness. We sought to investigate factors that may contribute to this phenomenon, with a particular focus on the antecedent underutilization of appropriate preoperative studies. METHODS: We reviewed patient data from a pediatric epilepsy clinic over an 18-month period. Patients with drug-resistant epilepsy (DRE) were categorized according to brain magnetic resonance imaging (MRI) findings (lesional, MRI-negative, or multifocal abnormalities) and type of epilepsy diagnosis based on semiology and electroencephalography (EEG) (focal or generalized). We then analyzed the rates of diagnostic test utilization, surgical referral, and subsequent epilepsy surgery as well as vagus nerve stimulation (VNS). RESULTS: Of the 249 patients with a diagnosis of epilepsy, 138 (55.4%) were found to have DRE. Excluding the 10 patients with DRE who did not undergo MRI, 76 patients (59.4%) were found to be MRI-negative (non-lesional epilepsy), 37 patients (28.9%) were found to have multifocal abnormalities, and 15 patients (11.7%) were found to have a single epileptogenic lesion on MRI (lesional epilepsy). Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) were each completed in nine patients (7.0%) and magnetoencephalography (MEG) in four patients (3.1%). Despite the low utilization rate of adjunctive studies, over half (56.3%) ultimately underwent VNS alone, and 8.6% ultimately underwent definitive intracranial resection or disconnection surgery. CONCLUSIONS: The underutilization of appropriate non-invasive, presurgical testing in patients with focal DRE may in part explain the continued underutilization of definitive, resective/disconnective surgery. For patients without access to a high-volume, multidisciplinary surgical epilepsy center, adjunctive presurgical studies [e.g., PET, SPECT, MEG, electrical source imaging (ESI), EEG-functional magnetic resonance imaging (fMRI)], even when available, are rarely ordered, and this may contribute to excessive rates of VNS in lieu of definitive intracranial surgery.

Unsupervised Machine Learning Identifies Quantifiable Patterns of Visual Field Loss in Idiopathic Intracranial Hypertension.

Purpose: Archetypal analysis, a form of unsupervised machine learning, identifies archetypal patterns within a visual field (VF) dataset such that any VF is described as a weighted sum of its archetypes (ATs) and has been used to quantify VF defects in glaucoma. We applied archetypal analysis to VFs affected by nonglaucomatous optic neuropathy caused by idiopathic intracranial hypertension (IIH). Methods: We created an AT model from 2862 VFs prospectively collected from 330 eyes in the IIH Treatment Trial (IIHTT). We compared baseline IIH AT patterns with their descriptive VF classifications from the IIHTT. Results: The optimum IIH AT model yielded 14 ATs resembling VF patterns reported in the IIHTT. Baseline VFs contained four or fewer meaningful ATs in 147 (89%) of study eyes. AT2 (mild general VF depression pattern) demonstrated the greatest number of study eyes with meaningful AT weight at baseline (n = 114), followed by AT1 (n = 91). Other ATs captured patterns of blind spot enlargement, hemianopia, arcuate, nasal defects, and more nonspecific patterns of general VF depression. Of all ATs, AT1 (normal pattern) had the strongest correlation with mean deviation (r = 0.69, P < 0.001). For 65 of the 93 VFs with a dominant AT, this AT matched the expert classification. Conclusions: Archetypal analysis identifies quantifiable, archetypal VF defects that resemble those commonly seen in IIH. Translational Relevance: Archetypal analysis provides a quantitative, objective method of measuring and monitoring disease-specific regional VF defects in IIH.

Primary and Secondary Optic Nerve Sheath Meningioma.

Objective This study was aimed to review issues relating to the recognition, radiographic diagnosis, monitoring, and management of primary and secondary optic nerve sheath meningioma (ONSM). Design This study is a review of peer-reviewed literature combined with illustrative case studies. Participants and Methods A literature search was conducted via the PubMed database using pertinent search terms. Selected articles were limited to those written or translated into English. Additional works cited within articles were also included. Individual cases were drawn from the experience of a tertiary academic neuroophthalmic and orbital practice. Tables summarize radiotherapeutic and surgical studies, excluding single case reports and studies focusing on meningioma of intracranial origin. Main Outcome Measurements Review of reported surgical and radiotherapeutic series is the primary measurement. Results The natural history of optic nerve sheath meningiomas is primarily characterized by progressive ipsilateral vision loss. Diagnosis is typically based on radiographic imaging findings, with biopsy remaining indicated in some patients. Management strategies may include observation, radiation, and/or surgical intervention, or a combination of these approaches. The role of surgery, especially with respect to primary ONSM (pONSM), remains controversial. Advancement of radiotherapy techniques has shifted modern treatment paradigms in pONSM toward radiation as primary treatment, as surgical outcomes are inferior in major studies. Although radiation remains the treatment of choice in many cases, selected patients may benefit from surgery, especially in the setting of secondary ONSM (sONSM). Conclusion A wide variety of radiotherapeutic and surgical treatment modalities for ONSM exist. The specific indications for each management strategy continue to be redefined.

Posterior Approach for a Ventral Intradural Extramedullary Meningioma: 2-Dimensional Operative Video.

Ventral thoracic meningiomas are rare entities in which the spinal cord is attenuated and draped over the meningioma symmetrically. This is a challenging surgical entity compared to typical intradural meningiomas, which nearly always eccentrically displace the cord. In these more common meningiomas, surgical access is fairly straightforward as the meningioma is often visualized upon opening the meninges. Resection can be more safely performed with the cord largely shifted. In cases of ventral meningioma, the tumor is hidden ventral to the spinal cord, and techniques to safely mobilize the spinal cord must be utilized. We demonstrate that an entirely posterior approach allows complete resection of a ventrally situated mass. After careful identification and sectioning of the dentate ligament at multiple levels on the right side of the canal, we then suture and rotate the dentate ligament at each site, thereby allowing progressive visualization of the ventral meningioma. A narrow, but viable, working corridor to the tumor allows safe debulking. Once it is felt that the tumor can no longer be safely excised through the created corridor, we then disconnect our dentate sutures and move to the other side of the canal. Similarly, the dentate is sectioned and sutured so that the contralateral aspect of the meningioma can be visualized and debulked. The tumor can then be safely removed. A standard posterior approach and midline durotomy allows this bilateral approach to a ventrally situated meningioma and, therefore, in our mind, represents a safe and also highly effective road to resection. Patient consent was obtained prior to publication.

Deciphering the surgical treatment gap for drug-resistant epilepsy (DRE): A literature review.

Patients with drug-resistant epilepsy (DRE) rarely achieve seizure freedom with medical therapy alone. Despite being safe and effective for select patients with DRE, epilepsy surgery remains heavily underutilized. Multiple studies have indicated that the overall rates of surgery in patients with DRE have stagnated in recent years and may be decreasing, even when hospitalizations for epilepsy-related problems are on the rise. Ultimately, many patients with DRE who might otherwise benefit from surgery continue to have intractable seizures, lacking access to the full spectrum of available treatment options. In this article, we review the various factors accounting for the persistent underutilization of epilepsy surgery and uncover several key themes, including the persistent knowledge gap among physicians in identifying potential surgical candidates, lack of coordinated patient care, patient misconceptions of surgery, and socioeconomic disparities impeding access to care. Moreover, factors such as the cost and complexity of the preoperative evaluation, a lack of federal resource allocation for the research of surgical therapies for epilepsy, and difficulties recruiting patients to clinical trials all contribute to this multifaceted dilemma.

Treatment options and long-term outcomes in pediatric spinal cord vascular malformations: a case report and review of the literature.

A 16-month-old female was admitted for prolonged fever, gait ataxia, and neurogenic bowel and bladder. Neurological exam was significant for decreased sensory and motor functions in bilateral lower extremities. Initial MRI showed a thoracic spine hematoma and diagnostic angiogram revealed a large AVM and aneurysm. The patient underwent surgical resection of the hematoma and AVM, as well as clipping and later endovascular coiling of the aneurysm. Due to significant hemorrhage perioperatively, she developed spastic paraplegia improved by baclofen and onabotulinumtoxin A injections. The aims of this paper were to conduct a systematic review of the literature on pediatric spinal cord vascular malformations and analyze trends in treatment options and long-term neurological outcomes. PubMed searches were conducted using keywords "pediatric spinal vascular malformation" and "pediatric spinal AVM", yielding 34 results after abstract screening and cross-reference. Endovascular embolization was determined to have better long-term outcomes, with 10/19 (52.6%) patients with postoperative complications associated with open vascular surgeries. Open versus endovascular surgical decisions can be difficult with unique spinal AVM pathologies in pediatric patients. Important considerations such as size, location, neurological deficits, and risk of rupture are important factors to consider in treating these patients. We recommend endovascular treatment as a first-line approach due to lower risk of hemorrhage and postoperative deficits.

Resection of a posterior fossa arteriovenous malformation complicated by leaked Onyx: a case report and review of literature.

Extravasation of Onyx is a rare complication during embolization of arteriovenous malformations (AVM). We present a case of embolization that was complicated by leakage of Onyx into the cerebellum which was later encountered during surgical excision of the AVM. Our goal is to report this rare event and to outline successful treatment of this complication. The patient's records were reviewed for medical history, laboratory and radiologic workup, and outpatient clinical follow-up. A 62-year-old female presented with Hunt Hess grade 2 and modified Fisher grade 2 subarachnoid hemorrhage (SAH) secondary to ruptured left posterior inferior cerebellar artery (PICA) aneurysm associated with a superior cerebellar vermian AVM. Following endovascular intervention, the aneurysm was completely embolized; however, only 75% of the AVM could be safely obliterated. Extravasation of Onyx from the ruptured aneurysm was noted on her initial angiogram. Elective suboccipital craniectomy was subsequently planned for resection of the residual AVM where the extravasated Onyx posed an operative nuisance during resection. Post-op angiogram confirmed complete resection of the AVM, as well as the bulk of the extravasated Onyx. Patient did well post-operatively, remaining neurologically intact throughout her hospital course. Although infrequently reported in the literature, Onyx extravasation is a potential complication that neurosurgeons should be ready to face. Adherence of Onyx to surrounding parenchyma could hinder optimal surgical resection of AVM and increase complications. Therefore, careful surgical dissection should be performed with special care to delicate neurovasculature. In this case, complete resection of the AVM and Onyx mass was safely achieved.

Temporal evolution of a patient with a spinal dural arteriovenous fistula on serial MRI.

INTRODUCTION: A spinal dural arteriovenous fistula is a rare type of vascular malformation. If left untreated, these fistulas can result in significant neurological deficits secondary to spinal cord infarct or hemorrhage. CASE PRESENTATION: A 70-year-old female with a longstanding history of episodic progressive bilateral lower extremity weakness and sensory disturbances was previously misdiagnosed with multiple sclerosis. Imaging revealed a T2 signal change from T7 to the conus with associated signal change and she subsequently underwent a T10-L1 laminectomy for clip ligation of a spinal dural arteriovenous fistula. Here we present the clinical and radiographic progression of one patient with a spinal dural arteriovenous fistula. DISCUSSION: Spinal dural arteriovenous fistulas are a rare but treatable cause of myelopathy, so it is important to understand its natural progression and radiologic findings as it is frequently misdiagnosed.

Spinal Cord Compression Secondary to Extramedullary Hematopoiesis: Case Report and Review of the Literature.

Extramedullary hematopoiesis (EMH) is a rare cause of spinal cord compression (SCC). EMH represents the growth of blood cells outside of the bone marrow and occurs in a variety of hematologic illnesses, including various types of anemia and myeloproliferative disorders. Although EMH usually occurs in the liver, spleen, and lymph nodes, it may also occur within the spinal canal. When this occurs, the mass effect can compress the spinal cord, potentially leading to the development of neurological deficits. We present a case of SCC secondary to EMH. This report illustrates the importance of considering EMH in the differential diagnosis of SCC, even in the absence of signs of its most common etiologies.

Metastatic Mantle Cell Lymphoma to the Pituitary Gland: Case Report and Literature Review.

We present an unusual case of a metastatic mantle cell lymphoma (MCL) to the pituitary gland. The patient had a known history of MCL for which she previously received chemotherapy. She presented with new-onset diplopia and confusion, and reported a history of progressive vision blurriness associated with headache, nausea, and vomiting. MRI of the brain showed an enhancing lesion within the sella turcica involving the cavernous sinuses bilaterally, extending into Meckel's cave on the left, and abutting the optic nerves bilaterally. Following surgical excision, histopathology revealed the tumor to be a MCL. Metastatic pituitary tumors are rare and have been estimated to make up 1% of tumors discovered in the sellar region. The two most common secondary metastatic lesions to the sella are breast and lung carcinoma followed by prostate, renal cell, and gastrointestinal carcinoma. Metastatic lymphoma to the pituitary gland is especially rare and is estimated to constitute 0.5% of all metastatic tumors to the sella turcica. To our knowledge, this is the first reported case of MCL metastasizing to the pituitary gland.

Delayed Tension Pneumocephalus following Gunshot Wound to the Head: A Case Report and Review of the Literature.

Tension pneumocephalus is a rare complication of head trauma and neurosurgical procedures, amongst other causes. It is defined by the combination of intracranial air, increased intracranial pressure, and mass effect. Although it often presents soon after surgery, it can also rarely present in a delayed fashion. We present a case of delayed tension pneumocephalus, occurring approximately 16 weeks after bifrontal craniectomy for a self-inflicted gunshot wound. Following a month of rhinorrhea, postnasal drip, and cough, the patient presented with a sensation of expansion in the area of the right forehead. As tension pneumocephalus is an emergency that can be fatal, this patient was treated expediently and avoided severe neurological deficits. The case recounted here is important as a demonstrative example that tension pneumocephalus does not always follow a defined course immediately after trauma or neurosurgery but rather can develop insidiously without obvious signs.