Natural history of adenoviral conjunctivitis in a US-based population: Viral load, signs, and symptoms.

PURPOSE: To report the clinical signs, symptoms, and viral clearance in individuals in the United States with adenoviral conjunctivitis (Ad-Cs). METHODS: Individuals ≥ 18 years presenting within 4 days of symptoms of Ad-Cs who met eligibility criteria and tested positive with both point-of-care immunoassay antigen and quantitative polymerase chain reaction (qPCR) testing were enrolled. Patient-reported symptoms, clinician-graded signs, and qPCR viral titers were collected at baseline, days 1-2, 4 (days 3-5), 7 (days 6-10), 14 (days 11-17) and 21 (days 18-21). RESULTS: There was no detectable viral titers by the day 14 visit in 6/8 patients. By day 21, there was no detectable viral titers in the 7 participants who completed the visit; however, signs and symptoms persisted including: blurry vision (5/7), discomfort (2/7) or redness (1/7). Masked clinicians also noted conjunctival redness (4/7), follicular conjunctivitis (4/7) and bulbar edema (3/7). CONCLUSION: Many patient-reported symptoms and clinical signs persist after viral titers are no longer detectable by qPCR. Using clinical signs and symptoms to determine quarantine duration may result in patients being furloughed longer than the time that the patient is infectious.

Efficacy of a Single Administration of 5% Povidone-Iodine in the Treatment of Adenoviral Conjunctivitis.

PURPOSE: To evaluate the safety and efficacy of a single, in-office administration of 5% povidone-iodine (PVP-I) compared to artificial tears (AT) for adenoviral conjunctivitis (Ad-Cs). DESIGN: Double-masked pilot randomized trial. METHODS: Patients presenting with presumed adenoviral conjunctivitis were screened at 9 U.S. clinics. INCLUSION CRITERIA: ≥18 years of age, symptoms ≤4 days, and a positive AdenoPlus test. EXCLUSION CRITERIA: thyroid disease, iodine allergy, recent ocular surgery, and ocular findings inconsistent with early-stage Ad-Cs. Randomization was to a single administration of 5% PVP-I or AT in 1 eye and examinations on days 1-2, 4, 7, 14, and 21 with conjunctival swabs taken at each visit for quantitative polymerase chain reaction. Primary outcome was percent reduction from peak viral load. Secondary outcomes were improvement in clinical signs and symptoms. RESULTS: Of 56 patients randomized, 28 had detectable viral titers at baseline. Day 4 posttreatment, viral titers in the 5% PVP-I and AT groups were 2.5% ± 2.7% and 14.4% ± 10.5% of peak, respectively (P = .020). Severity of participant-reported tearing, lid swelling, and redness as well as clinician-graded mucoid discharge, bulbar redness, and bulbar edema were lower in the 5% PVP-I group than AT group on day 4 (P < .05). After day 4, viral titers and severity of signs and symptoms decreased markedly in both groups and no differences between groups were detected. CONCLUSIONS: Pilot data suggest a single, in-office administration of 5% PVP-I could reduce viral load and hasten improvement of clinical signs and symptoms in patients with Ad-Cs.

Femtosecond laser-assisted anterior lamellar keratoplasty with suboptimal outcomes: a case series / Ceratoplastia lamelar anterior assistida por laser de femtosegundo com resultados subótimos: uma série de casos

ABSTRACT Objective To identify preoperative clinical characteristics of patients undergoing femtosecond laser-assisted anterior lamellar keratoplasty who failed to achieve optimal postoperative visual outcomes. Methods In this single-center, retrospective case series, patients who underwent femtosecond laser-assisted anterior lamellar keratoplasty between 2013 and 2018 were included if they required graft revision, subsequent corneal procedure, or additional postoperative visits for a femtosecond laser-assisted anterior lamellar keratoplasty-related issue. Visual outcomes assessed included best-corrected visual acuities and postoperative corneal astigmatism. Results Eight eyes of eight patients meeting the above criteria were included. Mean patient age was 64.5 years (range, 21 to 89 years). Mean included preoperative best-corrected visual acuities was one logarithm of the minimum angle of resolution (range, 0.3 logarithm of the minimum angle of resolution to counting fingers). Indications for femtosecond laser-assisted anterior lamellar keratoplasty included anterior stromal scarring due to viral keratitis (two cases), bacterial keratitis (one case), chronic epithelial defect (one case), Avellino dystrophy (one case), trauma (one case), and chronic endothelial failure (two cases). Six patients had history of prior intraocular surgeries including phacoemulsification (four cases), pars plana vitrectomy (one case), endothelial keratoplasty (two cases), and trabeculectomy (one case). Mean included best-corrected visual acuities at most recent follow-up was one logarithm of the minimum angle of resolution (range zero logarithm of the minimum angle of resolution to hand movements) representing improvement or stability in six of eight patients. Visually significant corneal astigmatism was present in four of eight patients. Post-femtosecond laser-assisted anterior lamellar keratoplasty procedures included graft repositioning, arcuate keratotomy, phacoemulsification, and regraft. Conclusion While femtosecond laser-assisted anterior lamellar keratoplasty offers a less-invasive treatment option compared to penetrating keratoplasty, intraoperative and postoperative management can be complex. Femtosecond laser-assisted anterior lamellar keratoplasty in patients with history of prior endothelial keratoplasty or ongoing ocular comorbidities should be pursued with caution.

RESUMO Objetivo Identificar as características clínicas pré-operatórias de pacientes submetidos à ceratoplastia lamelar anterior assistida por laser de femtossegundo que não alcançaram resultados visuais pós-operatórios ideais. Métodos Nesta série de casos retrospectiva em um único centro, os pacientes submetidos à ceratoplastia lamelar anterior assistida por laser de femtossegundo entre 2013 e 2018 foram incluídos se precisassem de revisão do enxerto, procedimento corneano subsequente ou visitas pós-operatórias adicionais por uma intercorrência relacionada à ceratoplastia lamelar anterior assistida por laser de femtossegundo. Os resultados visuais avaliados incluíram melhor acuidade visual corrigida e astigmatismo pós-operatório da córnea. Resultados Oito olhos de oito pacientes que atenderam aos critérios descritos foram incluídos. A idade média dos pacientes foi de 64,5 anos (variação de 21 a 89). A melhor acuidade visual corrigida pré-operatória média foi de um logaritmo do mínimo ângulo de resolução (variação de 0,3 logaritmo do mínimo ângulo de resolução para contagem de dedos). As indicações para ceratoplastia lamelar anterior assistida por laser de femtossegundo incluíram cicatriz do estroma anterior devido à ceratite viral (dois casos), ceratite bacteriana (um caso), defeito epitelial crônico (um caso), distrofia de Avellino (um caso), trauma (um caso) e insuficiência endotelial crônica (dois casos). Seis pacientes tinham história de cirurgias intraoculares anteriores, incluindo facoemulsificação (quatro casos), vitrectomia via pars plana (um caso), ceratoplastia endotelial (dois casos) e trabeculectomia (um caso). O mínimo ângulo de resolução médio no acompanhamento mais recente foi de um logaritmo do mínimo ângulo de resolução (variação de zero logaritmo do mínimo ângulo de resolução para movimentos das mãos), representando melhora ou estabilidade em seis de oito pacientes. Astigmatismo corneano visualmente significativo estava presente em quatro de oito pacientes. Os procedimentos pós-ceratoplastia lamelar anterior assistida por laser de femtossegundo incluíram reposicionamento do enxerto, ceratotomia arqueada, facoemulsificação e enxerto. Conclusão Embora a ceratoplastia lamelar anterior assistida por laser de femtossegundo ofereça uma opção de tratamento menos invasiva em comparação com a ceratoplastia penetrante, o manejo intra e pós-operatório pode ser complexo. A ceratoplastia lamelar anterior assistida por laser de femtossegundo em pacientes com história de ceratoplastia endotelial anterior ou comorbidades oculares correntes deve ser avaliada com cautela.

Incidence of Management Changes at the Postoperative Week 1 Visit after Cataract Surgery: Results from the Perioperative Care for IntraOcular Lens Study.

PURPOSE: To ascertain the incidence of unexpected management changes at the postoperative week 1 visit in asymptomatic patients who have had an uncomplicated cataract surgery and a routine postoperative day 1 examination. DESIGN: Retrospective observational study. METHODS: A retrospective chart review was conducted of all cases of cataract extraction by phacoemulsification with intraocular lens insertion performed by the Comprehensive Ophthalmology Service at Massachusetts Eye and Ear between January 1, 2014 and December 31, 2014. The preoperative consultation, operative report, and postoperative day 1 and week 1 (postoperative days 5-14) visits were reviewed. Cases with intraoperative complications, as well as clinical findings at postoperative day 1 requiring close follow-up, were excluded. The main outcome measure was incidence of unexpected management changes at the postoperative week 1 visit after cataract surgery, defined as an unanticipated change in postoperative drops, additional procedures, or urgent referral to a specialty service. RESULTS: Overall, 1938 surgical cases of 1471 patients were reviewed, and 1510 cases (77.9%) underwent uncomplicated phacoemulsification with intraocular lens implantation with a routine postoperative day 1 examination. Of these 1510 cases, 238 (15.8%) reported symptoms at the postoperative week 1 visit, including flashes, floaters, redness, pain, or decreased vision, which warranted an examination. In total, 1272 cases were asymptomatic, and only 11 of these cases (0.9%) had an unexpected management change at postoperative week 1. Eight of 11 patients were asymptomatic steroid responders requiring alteration of their postoperative drops. Two of these patients had an intraocular pressure >30 mm Hg. CONCLUSIONS: Unexpected management changes at the postoperative week 1 timepoint after cataract surgery are rare in asymptomatic patients who have had uncomplicated cataract surgery and a routine postoperative day 1 examination. Limited data are available to outline an optimal postoperative regimen after cataract surgery. The results of this study suggest that postoperative week 1 examinations could potentially be performed on an as-needed basis in the appropriate subgroup of patients after cataract surgery.

BILATERAL CENTRAL RETINAL VEIN OCCLUSIONS IN A YOUNG PATIENT WITH A HISTORY OF EOSINOPHILIC PNEUMONIA AND THALAMIC STROKE.

PURPOSE: To describe a case of a central retinal vein occlusion in a young patient with a history of eosinophilic pneumonia. METHODS: A retrospective case report of a 45-year-old woman with acute painless vision loss for 9 days after multiple episodes of eosinophilic pneumonia and thalamic stroke. Fluorescein angiography, spectral domain optical coherence tomography, and clinical examination were performed. She was then treated with intravitreal bevacizumab and pan-retinal photocoagulations. RESULTS: Retinal examination revealed tortuosity and dilatation of all branches of the central retinal vein and flame-shaped hemorrhages in all four quadrants of the right eye associated with cystoid macular edema, optic disc edema, and cotton wool spots. The left eye had mild venous dilatation and tortuosity with a few dot retinal hemorrhages in the far temporal periphery. The cystoid macular edema resolved after one intravitreal injection of bevacizumab and remained resolved at the most recent follow-up. Fluorescein angiography at the most recent follow-up revealed vasculitis in the far periphery of the nontreated eye. CONCLUSION: Central retinal vein occlusion in young patients is a rare condition often presenting as a manifestation of an underlying inflammatory or hematological disorder. Combined anti-vascular endothelial growth factor treatment and pan-retinal photocoagulation may have resolved the associated cystoid macular edema in this case, although continued observation is necessary.

Identification of RUNX1 as a Mediator of Aberrant Retinal Angiogenesis.

Proliferative diabetic retinopathy (PDR) is a common cause of blindness in the developed world's working adult population and affects those with type 1 and type 2 diabetes. We identified Runt-related transcription factor 1 (RUNX1) as a gene upregulated in CD31+ vascular endothelial cells obtained from human PDR fibrovascular membranes (FVMs) via transcriptomic analysis. In vitro studies using human retinal microvascular endothelial cells (HRMECs) showed increased RUNX1 RNA and protein expression in response to high glucose, whereas RUNX1 inhibition reduced HRMEC migration, proliferation, and tube formation. Immunohistochemical staining for RUNX1 showed reactivity in vessels of patient-derived FVMs and angiogenic tufts in the retina of mice with oxygen-induced retinopathy, suggesting that RUNX1 upregulation is a hallmark of aberrant retinal angiogenesis. Inhibition of RUNX1 activity with the Ro5-3335 small molecule resulted in a significant reduction of neovascular tufts in oxygen-induced retinopathy, supporting the feasibility of targeting RUNX1 in aberrant retinal angiogenesis.

Endophthalmitis After Intravitreal Injections in Patients With Self-reported Iodine Allergy.

PURPOSE: To present cases of endophthalmitis following intravitreal injections where povidone-iodine (PI) was not used as part of the surgical preparation. DESIGN: Retrospective case series. METHODS: All cases of presumed injection-related endophthalmitis presenting to the Massachusetts Eye and Ear Infirmary between June 2008 and November 2014 and Dean McGee Eye Institute between January 2010 and January 2015 were identified. Patients who did not receive PI preparation owing to documented self-reported allergy to iodine, iodine-containing contrast material, or shellfish were identified and their injection histories and clinical courses reviewed. RESULTS: The combined rate of postinjection endophthalmitis at these 2 centers was 0.019%. Among 42 patients with postinjection endophthalmitis, 5 (11.9%) did not receive PI prophylaxis. The mean number of intravitreal injections without PI before the development of endophthalmitis was 10.6 with a 9.4% rate of endophthalmitis (5 cases per 53 injections). All patients underwent tap-and-inject procedures with vancomycin 1 mg and ceftazidime 2 mg. Two patients did not receive PI at the time of tap and inject; 1 of these patients required subsequent pars plana vitrectomy for worsening clinical course. Cultures were positive in 4 of 5 cases; all positive cultures grew coagulase-negative Staphylococcus. All patients who received subsequent intravitreal injections received PI prophylaxis without allergic reactions, thus demonstrating a lack of true PI allergy. CONCLUSIONS: Avoiding PI owing to self-reported iodine "allergy" risks substantial ocular morbidity. Allergy testing can be pursued per patient request or in rare cases of suspected true PI allergy; however, in cases where delayed treatment would adversely affect visual outcome, the clinician should feel confident that minimal allergic risk exists.

Providing prescheduled appointments as a strategy for improving follow-up compliance after community-based glaucoma screening: results from an urban underserved population.

To determine if receiving a prescheduled appointment is associated with an increased likelihood of complying with follow-up eye care among individuals identified as at risk for glaucoma during community-based glaucoma screening in an urban underserved population. This study sampled 362 individuals aged ≥30 years without known glaucoma from low-income, predominantly black/Hispanic neighborhoods in New Haven, Connecticut presenting to one of twelve community-based glaucoma screening events from May 2010 to October 2012. A quasi-experimental design systematically assigned 63 individuals identified as at risk for glaucoma into either intervention or control group with a 1:2 ratio. Individuals in the control group (n = 41) received counseling on glaucoma and a recommendation for obtaining a follow-up appointment at the eye department of a local community health center, which offers affordable health services with income-adjusted fee discounts to uninsured, low-income patients. Those in the intervention group (n = 22) received the same counseling and a prescheduled appointment at the community health center. The overall rate of follow-up compliance within 3 months of screening was 30 % (41 % in the intervention group; 24 % in the control group). Multivariate logistic regression analysis adjusting for sex, age, ethnicity, health insurance status, car access, living situation, and smoking status found that follow-up compliance was significantly associated with intervention (adjusted odds ratio 4.8; 95 % confidence interval 1.1-20.9). Providing prescheduled appointments can improve follow-up compliance after community-based glaucoma screening. This finding may be potentially applicable to community-based health screening for other preventable diseases.