Orbital mass as the presenting symptom of diffuse large B-cell lymphoma causing spontaneous tumor lysis syndrome and rapid multisystem organ failure.

A 68-year-old male presented with a one-month history of progressive proptosis and vision loss in the left eye. Examination of the left eye showed visual acuity of NLP, marked relative proptosis of 10 mm, and complete external ophthalmoplegia. CT orbits showed an extensive left orbital lesion with proptosis. Urgent orbital biopsy was undertaken. Intraoperatively, the patient developed new atrial flutter and fever. Bloodwork revealed metabolic derangements suggestive of tumor lysis syndrome. Systemic evaluation revealed a large tumor burden involving the retroperitoneal space. Histopathology of the orbital specimen showed non-germinal center diffuse large B-cell lymphoma. The patient passed away 3 days postoperatively due to rapidly progressive multisystem organ failure. Our case demonstrates an unusually aggressive presentation of DLBCL in which orbital mass was the first presentation of spontaneous tumor lysis syndrome owing to large systemic tumor burden.

Incidence of ocular hypertension after anti-VEGF injections: examining the effect of drug filtration and silicone-free syringes.

OBJECTIVE: To examine the difference in incidence of ocular hypertension (OHT) following the introduction of filtered anti-vascular endothelial growth factor (anti-VEGF) medication in silicone-free syringes. DESIGN: Retrospective cohort study. METHODS: A retrospective review of consecutive treatment-naive patients receiving intravitreal anti-VEGF injections in a group practice was performed. Data from the cohort receiving nonfiltered anti-VEGF in insulin syringes (IS group) was collected from June 2015. Data from the cohort receiving filtered anti-VEGF in silicone-free syringes (SFS group) was collected from June 2019. Follow up data were collected at 1 year. Exclusion criteria included prior anti-VEGF treatment, known glaucoma or diagnosis of glaucoma suspect before anti-VEGF treatment, neovascular glaucoma, steroid use, or vitrectomy during follow-up. Primary outcome was the cumulative incidence of intraocular pressure (IOP) > 21 mmHg and IOP ≥ 30 mm Hg at any follow-up visit. The use of IOP lowering therapy was also recorded. RESULTS: The mean age (71 ± 13 years), mean number of injections (9.6 ± 2.7), and median follow-up time (392 ± 57 days) were similar between groups. The incidence of IOP ≥ 21 mm Hg was 34% (34/100) in the IS group and 15% (15/100) in the SFS group (p = 0.025). The incidence of IOP ≥ 30 mm Hg was 8% (8/100) in the IS group and 0% (0/100) in the SFS group (p =0.004). The incidence of IOP-lowering therapy was 13% in the IS group and 0% in the SFS group (p =0.0002). CONCLUSION: The incidence of OHT and treatment with IOP-lowering therapy significantly decreased after the introduction of filtered anti-VEGF medication and silicone-free syringes.

Risk of maculopathy with pentosan polysulfate sodium use.

AIMS: Recent epidemiologic studies have examined the risk of maculopathy with pentosan polysulfate sodium (PPS), a drug indicated for the treatment of interstitial cystitis. However, results have been contradictory. Thus, we quantified the risk of maculopathy with PPS with a focus on risk with duration of use. METHODS: We used a new user, retrospective cohort study with an active comparator. We created a cohort of mutually exclusive 6221 PPS users and 89 744 amitriptyline users, a tricyclic antidepressant also used for the treatment of pain secondary to interstitial cystitis. Subjects were selected from the PharMetrics Plus database (IQVIA, Durham, NC) from 2006 to 2020. Cohort members were followed to the first event of the study outcome (maculopathy) or end of enrolment. A Cox regression model was constructed to adjust for potential confounders. RESULTS: The mean follow-up was 3.0 years for PPS users and amitriptyline users. The adjusted hazard ratio (HR) for maculopathy in PPS users was 2.64 (95% confidence interval [CI]: 1.90-3.68). The HR for the sensitivity analysis that combined maculopathy and age-related macular degeneration (AMD) was 1.38 (95% CI: 1.16-1.65). A cumulative duration-response pattern was observed, with use greater than 3 years having a 9.5-fold risk of maculopathy (HR = 9.56, 95% CI: 3.60-25.37) compared to a 2.3-fold risk of maculopathy with use for 1 year or less (HR = 2.27, 95% CI: 1.50-3.43). The number needed to harm for the first 4 years of use was 250. CONCLUSIONS: The results of this study suggest an increased risk of maculopathy with PPS use, particularly with longer duration of use.

Long-term Outcomes of Cataract Surgery in Patients With Chronic Ocular Graft-Versus-Host Disease.

PURPOSE: The aim of this study was to evaluate the outcomes of cataract surgery in patients with chronic ocular graft-versus-host disease (GVHD). METHODS: A retrospective review was performed on 77 eyes of 42 patients with chronic ocular GVHD that underwent cataract surgery between January 2014 and February 2020 in a tertiary institution. RESULTS: Posterior subcapsular cataract was seen in 53 (68.8%) of 77 eyes, with a mean preoperative corrected distance visual acuity (CDVA) of 0.61 ± 0.49 logarithm of the minimum angle of resolution (logMAR). Postoperatively, with a mean follow-up of 21 months, CDVA improved to 0.17 ± 0.22 logMAR at the latest visit (P < 0.0001). With latest available refraction, 42 (57.5%) of 73 eyes were within 0.5 diopters of target refraction, and 59 eyes (80.8%) were within 1.0 diopter. Postoperative complications included superficial punctate keratopathy within 1 month postoperatively (19 eyes, 24.7%), posterior capsular opacification requiring yttrium-aluminum-garnet (YAG) laser capsulotomy (36 eyes, 46.8%), corneal epithelial defect (7 eyes, 9.1%), filamentary keratopathy (5 eyes, 6.5%), cystoid macular edema (3 eyes, 3.9%), and infectious crystalline keratopathy (1 eye, 1.3%). Lower preoperative National Institutes of Health ocular GVHD severity scores were associated with a better postoperative CDVA (grade 1, 0.13 ± 0.16 logMAR; grade 2, 0.16 ± 0.23 logMAR; and grade 3, 0.36 ± 0.21 logMAR; P = 0.004). CONCLUSIONS: Cataract surgery improves visual acuity long term in most patients with chronic ocular GVHD. Close postoperative monitoring is important to detect ocular surface inflammation secondary to chronic ocular GVHD, particularly in severe ocular GVHD.

Incidence and Outcomes of Cystoid Macular Edema after Descemet Membrane Endothelial Keratoplasty (DMEK) and DMEK Combined with Cataract Surgery.

PURPOSE: To investigate the incidence and outcomes of cystoid macular edema (CME) after Descemet membrane endothelial keratoplasty (DMEK) alone and DMEK combined with cataract surgery (DMEK triple). MATERIALS AND METHODS: A retrospective chart review was performed for patients who underwent DMEK and DMEK triple between January 2014 and March 2018 at two tertiary hospitals. Patients with minimum of 6 months of follow-up were included. Logistic regression analysis was used to identify potential risk factors for CME including gender, age, glaucoma, uveitis, epiretinal membrane, diabetes mellitus, iridotomy, and rebubbling. RESULTS: 09 eyes of 193 patients who underwent DMEK (124 eyes) and DMEK triple (85 eyes) were included. The 6-month incidence of CME was 3.8% (8/209) for all cases, 2.4% (2/85) for DMEK triple, and 4.8% (6/124) for DMEK alone. CME was treated with topical prednisolone acetate 1% and nepafenac four times daily, and/or periocular triamcinolone acetonide, with resolution in all cases. On average, CME was detected 8.9 ± 2.1 weeks postoperatively, with a mean time to resolution of 4.1 ± 1.7 months. The 6-month best-corrected distance visual acuity of eyes that developed CME was not significantly different compared to eyes that did not develop CME (0.17 ± 0.15 logMAR vs. 0.23 ± 0.27 logMAR; p = .76). On logistic regression analysis, no risk factors for developing CME were identified. CONCLUSIONS: The incidence of CME after DMEK was low and not associated with decreased long-term visual acuity. Most cases of CME occurred between 1 and 3 months postoperatively. Predictive factors for CME after DMEK require further study.

Refractive Outcomes of Descemet Membrane Endothelial Keratoplasty Combined With Cataract Surgery in Fuchs Endothelial Dystrophy.

PURPOSE: To evaluate the refractive outcomes of Descemet membrane endothelial keratoplasty combined with cataract surgery (DMEK triple) in patients with Fuchs endothelial dystrophy. METHODS: A retrospective analysis of 68 eyes of 68 patients with Fuchs endothelial dystrophy who underwent DMEK triple between 2014 and 2018. RESULTS: The mean age of patients was 66.5 ± 8.6 years, and 65% (44 of 68) were female. Mean target refraction was -0.69 diopters (D) (interquartile range: -0.80 to -0.50 D). At 6 months, 47% (32 of 68) and 63% (43 of 68) of eyes were within ±0.50 and ±1.00 D of target refraction, respectively. Among eyes greater than 0.50 D from target, 78% (28 of 36) were hyperopic surprises. Mean spherical equivalent at 6 months was -0.14 ± 1.26 D, representing a mean hyperopic shift of 0.55 D from target. Preoperative pachymetry was higher in eyes with greater than 0.50 D of hyperopic surprise (648 ± 60 vs 613 ± 49 µm, P = .04). Refractive shift was greater in eyes with a preoperative central corneal thickness of 640 µm or greater versus eyes with a central corneal thickness of less than 640 µm (+1.20 ± 0.92 vs +0.40 ± 0.99 D, P = .02). None of the eyes with a preoperative central corneal thickness of 640 µm or greater shifted myopically compared to target (range: -0.09 to +2.89 D). CONCLUSIONS: A mean hyperopic shift of 0.55 D from target refraction occurred after DMEK triple, and 47% of eyes were within 0.50 D of target refraction at 6 months postoperatively. Thicker corneas preoperatively had greater hyperopic shift. A greater myopic target refraction may be warranted in eyes with a preoperative central corneal thickness of 640 µm or greater. [J Refract Surg. 2020;36(10):661-666.].

Measuring intraocular antibodies in eyes treated with anti-vascular endothelial growth factor.

OBJECTIVE: To characterize the total intraocular aqueous humour antibody profiles in cases receiving anti-vascular endothelial growth factor (anti-VEGF) for retinal vascular disease compared with controls without retinal pathology. DESIGN: Cross-sectional. PARTICIPANTS: 93 aqueous humour samples: 22 eyes undergoing cataract surgery (controls) and 71 eyes receiving intravitreal injections (IVI) (cases) for macular edema or neovascularization. METHODS: Antibody isotyping of aqueous humour was performed using Milliplex MAP Human Isotyping Multiplex Assay. Cases and controls were compared for several outcome measures. RESULTS: The primary outcome measure was total mean antibody isotype concentration quantified in the aqueous humour. Secondary outcomes included comparing aqueous humour concentrations with visual acuity, number of IVI received, type of anti-VEGF agent injected, and persistence intra-/subretinal fluid post injection. Mean immunoglobulin M (IgM) concentrations in cases were 19-fold higher compared with controls. Aqueous immunoglobulin G (IgG)1,2,3,4 and immunoglobulin A (IgA) were 2-4-fold higher in cases compared with controls. Disease-specific trends were observed, with diabetic retinopathy (DR) eyes containing the highest amounts of aqueous antibodies. Total number of injections correlated with higher titres of IgG1 (p < 0.001), IgG2 (p < 0.009), and IgG3 (p < 0.001) in all cases analyzed with the strongest correlations seen in DR eyes (r = 0.77, p < 0.001). Presence of aqueous humour antibodies correlated with worse post-IVI best-corrected visual acuity; IgG1 (p < 0.01), IgG2 (p < 0.005), IgG3 (p < 0.01), and IgA (p < 0.003) in all cases analyzed, with the strongest correlations seen in DR eyes (r = 0.74, p < 0.001). CONCLUSIONS: Intraocular antibodies are present in the aqueous humour at significantly higher concentrations in eyes receiving IVIs for retinal vascular diseases compared with controls.

Superficial keratectomy: indications and outcomes.

INTRODUCTION: To evaluate the indications and outcomes of manual blade superficial keratectomy STUDY DESIGN: Retrospective, nonrandomized, consecutive case series METHODS: Database search of patients from 2012-2017 who underwent superficial keratectomy was conducted at a tertiary care hospital cornea clinic. Charts of 121 patients (156 eyes) were reviewed who had at least 4 weeks of follow-up and both preoperative and postoperative measurements of best-corrected visual acuity or corneal cylinder. Outcome measures included: patient demographics, surgical indication, prior ocular history, best-corrected visual acuity (BCVA) changes, corneal and refractive astigmatism changes, recurrence of pathology, additional treatments required, and intraoperative and postoperative complications. RESULTS: Mean patient age at time of operation was 63.3 (±14.8), 39% were male. Indications included epithelial basement membrane dystrophy, recurrent corneal erosion syndrome, Salzmann nodular degeneration, band keratopathy, and suspected ocular surface neoplasia. In eyes with epithelial basement membrane dystrophy, mean BCVA (20/47 to 20/40, P = 0.033), refractive astigmatism (1.76 ± 1.83 D to 1.15 ± 1.08 D, P = 0.010), and corneal astigmatism (1.44 ± 0.88 D to 1.06 ± 0.88 D, P = 0.022) significantly improved. Twenty-four percent (5/21) of eyes with recurrent erosions had symptoms return at a mean 6.5 months follow-up. No intraoperative complications were noted. The epithelium healed completely in all 156 eyes at final follow-up. CONCLUSION: Superficial keratectomy is a simple, safe procedure that can be performed for a variety of conditions to improve visual acuity, reduce corneal astigmatism, and alleviate symptoms secondary to ocular surface pathology.

Metamorphopsia and vision-related quality of life among patients with age-related macular degeneration.

OBJECTIVE: To assess subjective and quantified metamorphopsia, as well as vision-related quality of life (QOL), in patients with age-related macular degeneration (AMD) to determine whether there is a correlation between quantified metamorphopsia and vision-related QOL in patients with AMD. METHODS: A cross-sectional study of patients with AMD. Patients who had a best-corrected visual acuity less than 20/200, vitreomacular adhesion, vitreomacular traction, epiretinal membrane, macular hole, macular edema by causes other than AMD, diabetic retinopathy, retinal detachment, previous retinal surgery, glaucoma, amblyopia, or strabismus were excluded. Subjective perceptions of metamorphopsia were captured by a validated 10-item questionnaire. M-CHARTS (Inami, Japan) was used to detect quantified metamorphopsia. Quantified metamorphopsia was scored horizontally and vertically. The mean values of 3 repeated examinations were used for data analysis. The 25-item National Eye Institute Visual Functioning Questionnaire (VFQ-25) was used to assess vision-related QOL. RESULTS: Among 102 eyes with AMD, the most commonly reported subjective perception of metamorphopsia included lines of words on books, newspapers, or computer displays (45.1%), followed by frames of windows or bookshelves (22.6%), lines of tiles on bathroom wall (21.6%), and people's faces (18.6%). Eyes with wet AMD had significantly higher horizontal and vertical metamorphopsia scores compared with eyes with dry AMD (p < 0.0001). The higher horizontal metamorphopsia score and the higher vertical metamorphopsia score between the 2 eyes were both negatively correlated with the NEI VFQ-25 composite score (Spearman rank correlation r = -0.3207, p = 0.0010; Spearman rank correlation r = -0.3190, p = 0.0011). CONCLUSIONS: In our study, the most common subjective metamorphopsia was distortion of lines of words on books, newspapers, or computer displays. Compared to eyes with dry AMD, those with wet AMD had higher quantified horizontal and vertical metamorphopsia. Between the 2 eyes, both the higher horizontal and vertical metamorphopsia scores were correlated with the NEI VFQ-25 composite score.

YouTube videos in the English language as a patient education resource for cataract surgery.

PURPOSE: To assess the quality of the content of YouTube videos for cataract surgery patient education. SETTING: Hotel Dieu Hospital, Kingston, Ontario, Canada. DESIGN: Observational study. METHODS: "Cataract surgery," "cataract surgery for patients," and "cataract surgery patient education" were used as search terms. The first two pages of search results were reviewed. Descriptive statistics such as video length and view count were obtained. Two cataract surgeons devised 14 criteria important for educating patients about the procedure. Videos were analyzed based on the presence or absence of these criteria. Videos were also assessed for whether they had a primary commercial intent. RESULTS: Seventy-two videos were analyzed after excluding 48 videos that were duplicate, irrelevant, or not in English. The majority of videos came from a medical professional (71%) and many depicted a real cataract surgery procedure (43%). Twenty-one percent of the videos had a primary commercial intent to promote a practice or product. Out of a total possible 14 points, the mean number of usefulness criteria satisfied was only 2.28 ± 1.80. There was no significant difference in view count between the most useful videos and other videos (p = 0.94). Videos from medical organizations such as the National Health Service were more useful (p < 0.0001). CONCLUSIONS: Cataract surgery videos are popular on YouTube, but most are not adequately educational. Patients may be receiving biased information from videos created with primary commercial intent. Physicians should be aware of the type of information patients may be accessing on YouTube.

Glaucoma Drainage Device Erosion Following Ptosis Surgery.

PURPOSE: To highlight the potential risk of glaucoma drainage device erosion following ptosis surgery. METHODS: Case report. RESULTS: A 71-year-old man underwent uncomplicated superotemporal Ahmed glaucoma valve implantation in the left eye in 2008. Approximately 8 years later, the patient underwent bilateral ptosis repair, which successfully raised the upper eyelid position. Three months postoperatively, the patient's glaucoma drainage implant tube eroded through the corneal graft tissue and overlying conjunctiva to become exposed. A graft revision surgery was successfully performed with no further complications. CONCLUSIONS: Caution and conservative lid elevation may be warranted when performing ptosis repair in patients with a glaucoma drainage implant, and patients with a glaucoma implant undergoing ptosis surgery should be followed closely for signs of tube erosion.