Optical coherence tomography predictors of progression of non-exudative age-related macular degeneration to advanced atrophic and exudative disease.

PURPOSE: To study the natural history of optical coherence tomography (OCT) imaging-based findings seen in non-exudative age-related macular degeneration (neAMD) and model their relative likelihood in predicting development of incomplete retinal pigment epithelium and outer retinal atrophy (iRORA), complete retinal pigment epithelium and outer retinal atrophy (cRORA), and neovascular AMD (nAMD). METHODS: Retrospective chart review was performed at two academic practices. Patients diagnosed with neAMD for whom yearly OCT scans were obtained for at least 4 consecutive years were included. Baseline demographic, visual acuity, AREDS staging, and OCT data were collected. OCTs were assessed for the presence or absence of eleven features previously individually associated with progression of neAMD, both at baseline, and on all subsequent follow-up scans. Likewise, charts were reviewed to assess visual acuity and staging of NEAMD at all follow-up visits. A multivariate regression analysis was constructed to determine predictors of iRORA, cRORA, and nAMD. RESULTS: A total of 107 eyes of 88 patients were evaluated. Follow-up included yearly OCTs obtained over at least 4 consecutive years follow-up (range: 50-94 months). During the follow-up period, 17 eyes progressed to iRORA while 25 progressed to cRORA and 16 underwent conversion to nAMD. Predictors of conversion to iRORA and cRORA included integrity of the external limiting membrane (p = 0.02), the ellipsoid zone (p = 0.01), and the cone outer segment line (p = 0.003) and the presence of intraretinal hyporeflective spaces (p = 0.009), drusen ooze (p = 0.05), and drusen collapse (p = 0.001). OCT features predictive of conversion to nAMD included outer nuclear layer (ONL) loss (p = 0.01), presence of intraretinal (p = 0.001) and subretinal (p = 0.005) hyporeflective spaces, and drusen collapse (p = 0.003). CONCLUSION: Of these multiple factors predictive of progression of neAMD, the OCT feature most strongly correlated to progression to iRORA/cRORA was drusen collapse, and the feature most predictive of conversion to nAMD was the presence of intraretinal hyporeflective spaces.

Drusen ooze: Predictor for progression of dry age-related macular degeneration.

BACKGROUND: To evaluate natural history of drusen ooze and its role as a predictor for progression of dry age-related macular degeneration (AMD) longitudinally. METHODS: Multi-centric retrospective observational case series of 72 eyes (72 patients) with dry AMD with a minimum follow-up of 4 years. Drusen types were identified on volume scans on optical coherence tomography (OCT) and were characterized for occurrence of drusen ooze at baseline until last visit. Drusen ooze was defined as hyperreflective dots overlying a collapsing drusen or pseudodrusen, or hyperreflective RPE above drusen or isoreflective dots at the level of outer nuclear layer. The consequent incidence of incomplete retinal pigment epithelium and outer retinal atrophy (iRORA), complete retinal pigment epithelium and outer retinal atrophy (cRORA), and neovascular AMD (nAMD) were evaluated statistically. RESULTS: In total, 72 eyes with a mean follow-up of 68.89 (± 25.57 months) were studied. At presentation, 11 eyes (15.3%) had a single drusen type, whereas 61 eyes (84.7%) had mixed drusen. Reticular pseudodrusen were most common (84.7%) followed by soft drusen (66.6%). Drusen ooze was seen in 47 eyes (65.2%) at presentation. The presence of drusen ooze at baseline (p < 0.01) and baseline best corrected visual acuity (BCVA) (p = 0.04) significantly correlated with development of iRORA and cRORA. In total, 14 eyes progressed from iRORA to cRORA over a mean follow up of 29.14 (± 24.33) months. Odds of progression to iRORA or cRORA were 20.3 times greater for eyes with drusen ooze at baseline (95% C.I., 4.4-94.2). CONCLUSIONS: In dry AMD, drusen ooze is a useful sign for predicting progression to iRORA and cRORA over time.

Bilateral evolution of OCT biomarkers in dry AMD: Long-term follow up study.

PURPOSE: To report the emergence and progress of four late-stage characteristics: incomplete retinal pigment epithelium and outer retinal atrophy (iRORA) and complete RPE and outer retinal atrophy (cRORA), drusen ooze and drusen collapse in eyes with dry age-related macular degeneration (AMD) using Spectral Domain Optical Coherence Tomography (SD-OCT). METHODS: This was a retrospective analysis of eyes with non-exudative AMD. Multimodal imaging was done at follow up visits ≤ 12 months. OCT volume scan was used to assess and identify the 4 characteristics. Univariate analysis was done for the various demographic and clinical characteristics.Patients with a mean age of 76.7 ± 10 years were followed up for 69.9 ± 20.6 months. iRORA, cRORA, drusen ooze was present in 15.6%, 15.6% and 15.6% of patients at baseline, respectively, and 25.0%, 40.6% and 53.1% of patients at the final follow-up, respectively. At baseline 9.1%, 0% and 9.1% of patients had bilateral drusen ooze, iRORA and cRORA, respectively. By the final follow-up, drusen collapse occurred in 46.9% and 18.8% patients in unilateral and bilateral eyes, respectively.For bilateral cases, the mean interval of time between emergence inthe two eyes for drusen ooze, drusen collapse, iRORA, and cRORA was 5 ± 1.4 years, 2.2 ± 2.2 years, 3.5 ± 0.7 and 1.7 ± 0.6 years, respectively. CONCLUSIONS: Late-stage OCT biomarkers are seen bilaterally at 21.9% at baseline and at 56.3% at 5.8 years follow-up. Once present in one eye, cRORA had the shortest mean interval before appearance in the other eye.

MULTIMODAL IMAGING OF MULTIFOCAL CHOROIDITIS WITH ADAPTIVE OPTICS OPHTHALMOSCOPY.

PURPOSE: To describe longitudinal, anatomical, and functional alterations caused by inflammatory and neovascular lesions of idiopathic multifocal choroiditis/punctate inner choroidopathy using adaptive optics imaging and microperimetry. METHODS: Longitudinal case study using multiple imaging modalities, including spectral-domain optical coherence tomography, fluorescein angiography, indocyanine green angiography, optical coherence tomography angiography, flood illumination adaptive optics, and microperimetry. RESULTS: A 21-year-old myopic Asian man presented with blurred vision in the right eye. Clinical examination was notable for an isolated hypopigmented, perifoveal lesion in each eye. Multimodal imaging showed inflammatory lesions in the outer retina, retina pigment epithelium, and inner choroid lesions of both eyes. The right eye additionally exhibited active Type-2 macular neovascularization with loss of cone mosaic regularity that was associated with reduced sensitivity on microperimetry. The clinical picture was consistent with multifocal choroiditis/punctate inner choroidopathy. The patient was treated with oral steroids and three injections of intravitreal bevacizumab in the right eye. After therapy, imaging showed reestablishment of the cone mosaic on flood illumination adaptive optics and improvement in sensitivity on microperimetry. CONCLUSION: Adaptive optics imaging and microperimetry may detect biomarkers that help to characterize the nature and activity of multifocal choroiditis lesions and to help monitor response to therapy. With timely intervention, structural abnormalities in the outer retina and choroid can be treated, and anatomical improvements precede improvements in visual function.

Endogenous Endophthalmitis: Recommendation for Empiric Dual Antibacterial and Antifungal Therapy.

Purpose: This work compares clinical presentation and course of bacterial and fungal causes of endogenous endophthalmitis (EE). Methods: A single-institutional study of consecutive patients diagnosed with EE was conducted at the University of Pittsburgh Medical Center between September 2015 and September 2018. Exclusion criteria included history of ocular trauma, intraocular surgery or injection 6 months before presentation, or primary external ocular infection. Data included demographics, medical and ocular history, clinical examination, culture data, therapeutic interventions, final corrected visual acuity (VA), and mortality. Results: Thirty-six eyes of 26 patients were diagnosed with EE during a 3-year period. Median age at diagnosis was 55.5 years (range, 19-86 years). Based on ocular and systemic cultures, 19 patients had bacterial EE and 6 patients had fungal EE; findings from all cultures remained negative in 1 patient. All patients had risk factors for EE. Presenting VA, subjective symptom report, and objective measures of intraocular inflammation were similar between bacterial and fungal causes. Overall, EE presented indolently and was initially misdiagnosed in 19% of cases. Complications including final VA less than 20/200, retinal detachment, enucleation, or death within 6 months of diagnosis were equivalent between bacterial and fungal cases. Conclusions: The presentation of EE is remarkably different from that of exogenous endophthalmitis. Without a high index of suspicion, the indolent presentation of EE may lead to misdiagnosis. No clinical features reliably differentiated bacterial and fungal sources. This highlights the importance of considering empiric therapy for antibacterial and antifungal coverage on initial presentation.

Eye-Related Emergency Department Visits and The Opioid Epidemic: a 10-Year Analysis.

PURPOSE: To describe the epidemiology of Emergency Department (ED) visits related to opioid abuse with primary ophthalmic diagnoses in the United States (US). METHODS: This retrospective cross-sectional study used National ED Sample (NEDS) (2006-2015), a representative sample of all US EDs, to analyze and compare the epidemiology of primary ophthalmic diagnoses in opioid abusers and a control group of non-opioid users. National incidence and descriptive statistics were calculated for demographics and prevalent diagnoses. Multivariable logistic regression was used to compare outcomes between primary ophthalmic diagnoses in opioid and non-opioid abusers. RESULTS: An estimated 10,617 visits had a primary ophthalmic diagnosis and an accompanying opioid abuse diagnosis, and the incidence increased from 0.2 in 2006 to 0.6 per 100,000 US population in 2015. Opioid abuse group had more adults (6,747:63.5%) and middle-aged (3,361:31.7%) patients, while in controls adults (7,905,003:40.4%) and children (4,068,534:20.8%) were affected more. Leading etiologies were similar: traumatic and infectious etiologies were most common; however, opioid abuse patients had more severe ophthalmic diagnoses such as orbital fractures (8.4%), orbital cellulitis (7.4%), globe injury (3.4%) and endophthalmitis (3.2%) compared to controls. Patients in the opioid abuse group were also more likely to be admitted (adjusted Odds Ratio [aOR], 28.38 [95% CI, 24.50-32.87]). CONCLUSIONS: In the era of opioid crisis, an increase in ED visits with ophthalmic complaints is seen, with increasing direct and indirect costs on the healthcare system. More research is needed to establish causality and devise strategies to lower this burden.

Clinical features of Streptococcus pyogenes keratitis: Case series.

PURPOSE: To characterize the risk factors, clinical presentations, management, outcomes, and microbiological properties of Streptococcus pyogenes keratitis. METHODS: Eight culture-proven cases (eight eyes) of S. pyogenes keratitis were diagnosed and treated between 2008 and 2018 at the University of Pittsburgh Medical Center (UPMC). Medical records were available for six patients, and these were reviewed to identify demographic information, systemic and ocular history, clinical presentations, antibiotic sensitivity, treatments, and outcomes of S. pyogenes isolates. RESULTS: Of the six charts reviewed, the median patient age was 67 years and all patients were female. Four patients had a history of cataract extraction more than one year prior to presentation, one had a history of improper contact lens use, and one had basement membrane dystrophy. Two patients, who also happened to have the most serious medical comorbidities, presented with corneal perforation on initial examination. The median follow-up length was 90.5 days. Visual outcomes varied greatly between patients. Three patients had visual acuity ranging from 20/30 to 20/70, while the two patients with corneal perforation had a final visual acuity of light perception, and one patient was lost to follow-up. Five of six isolates were susceptible to fluoroquinolones and all isolates were susceptible to cefazolin. CONCLUSIONS: S. pyogenes represented an uncommon ocular pathogen at UPMC eye clinic. However, if left untreated, this infection resulted in severe ocular morbidity. The majority of patients had a benign ocular history, suggesting that S. pyogenes can infect healthy corneas in immunocompetent patients. The majority of isolates were susceptible to cefazolin and fluoroquinolones.