REDUCTION OF POSTINTRAVITREAL INJECTION PAIN USING ICE: An Open-Label Interventional Randomized Controlled Trial.

PURPOSE: Intravitreal injections of intraocular therapeutic agents are a common and effective treatment for various retinal pathologies. Patient discomfort related to injection is a potential barrier to treatment. Our aim in this study was to evaluate whether cooling the eye using topical ice compresses before intravitreal injection will reduce pain or bleeding. METHODS: This randomized controlled open-label study included 42 patients. All patients received a standard topical anesthesia protocol and then were randomly assigned to either receive a placement of ice packs (intervention group) or a room-temperature pack (control group) on the eyelid, 2 minutes before the intravitreal injection. Patients' discomfort, itching, burning and pain (using visual analog scale), and bleeding size (using photographs) were measured 1 and 10 minutes after the injection. Tolerability was calculated by averaging patients' discomfort, itching, burning, and pain scores. RESULTS: At 1 minute, pain (1.95 vs. 4.27, P = 0.01) and overall tolerability (1.66 vs. 2.98, P = 0.03) were significantly lower in patients receiving ice packs. At 10 minutes, pain (1.6 vs. 3.73, P = 0.02), burning (0.9 vs. 3.09, P = 0.007), discomfort (2.1 vs. 4.27, P = 0.008), and overall tolerability (1.23 vs. 2.87, P = 0.004) were all significantly lower in the ice group compared with the controls. Bleeding size (area or circumference) was not statistical different between groups. CONCLUSION: Topical ice patch administered before intravitreal injection significantly decreased pain and overall tolerability. This simple and inexpensive method may be used to ameliorated pain and improve tolerability.

TOPICAL APRACLONIDINE REDUCES PAIN AFTER INTRAVITREAL INJECTIONS: A Double-Blind Randomized Controlled Trial.

PURPOSE: To evaluate the efficacy of topical apraclonidine in reducing pain and subconjunctival hemorrhage (SCH) after intravitreal injections (IViT). METHODS: A prospective, randomized, double-blinded study. Thirty-nine patients were examined twice, at each monthly IViT of 1.25 mg/0.05 mL bevacizumab. Patients were randomly assigned to receive either topical apraclonidine 0.5% or placebo to the treated eye, 30 minutes before the first IViT. At their second IViT, the intervention was switched. Thirty minutes after the injection, SCH size was measured by a slit lamp, and pain was assessed by the numerical rating scale (NRS-11). RESULTS: Mean pain score was 1.69 (SD ±1.44) in the apraclonidine group and 3.28 (SD ±2.27) in the control group (P < 0.001). Phakic patients had a greater pain reduction after topical apraclonidine (P < 0.001). Subconjunctival hemorrhage incidence was 41% in the apraclonidine group and 51.3% in the control group (P = 0.503). Mean SCH size was 1.71 mm (SD ±5.83) in the apraclonidine group and 3.25 mm (SD ±6.41) in the control group (P = 0.253). After topical apraclonidine, there was a smaller reduction in SCH size in patients with choroidal neovascularization or hypertension (P = 0.003 and 0.044, respectively), and a greater reduction in phakic patients (P = 0.048). CONCLUSION: Topical apraclonidine 0.5%, administered 30 minutes before IViT, significantly decreased pain by a factor of 1.94. It did not decrease the incidence or size of SCH in the entire cohort, but only in several subpopulations.

Photoreceptor Integrity Predicts Response to Anti-VEGF Treatment.

PURPOSE: Assessing changes in foveal photoreceptor microstructure (FPM) following intravitreal anti-VEGF treatment may serve as a prognostic marker in patients with macular edema (ME). METHODS: Sixteen eyes belonging to newly diagnosed patients with ME were included in this prospective longitudinal study. FPM integrity was evaluated at baseline and at the end of a series of anti-VEGF injections. RESULTS: Treatment led to a significant improvement in mean visual acuity (VA) and central macular thickness. A larger FPM defect was associated with lower VA, both before and after treatment. Patients with larger FPM defects at baseline had smaller VA improvements, and the improvement in FPM integrity was associated with VA improvement (every 100-µm FPM recovery contributed to a gain of 0.04 logMAR). CONCLUSIONS: Recovery of FPM after anti-VEGF treatment was significantly associated with a VA improvement. Direct measurement of photoreceptor integrity might provide an additional tool for the assessment of retinal function and treatment response in patients newly diagnosed with ME.

Inferior Oblique Muscle "Overaction" Caused by Inferior Oblique Muscle Shortening, Not by Hypertonicity.

PURPOSE: To determine whether fusional vergence adaptation in patients who can fuse in at least some gaze positions can cause curvature of the non-fixing eye movement paths of patients with apparent "overaction" or "underaction" of the oblique muscles, yielding possibly erroneous evidence of hypertonicity as the cause of the overaction or underaction. METHODS: The authors retrospectively studied Lancaster red-green plots of patients with oblique muscle "overaction/underaction." If fusion was present, the plot had usually been repeated after monocular occlusion for at least 30 minutes. Fundus torsion and fusion status were also recorded. RESULTS: After a patch test in patients displaying fusion, the non-fixing eye's movement path became more linear. CONCLUSIONS: Although it has been argued that true overaction of the oblique muscles would show curved eye movement paths on side gazes, in the study patients displaying fusion in at least some directions of gaze, the eye movement paths became more linear after patch testing, favoring the more mechanical explanation. Illustrated cases were consistent with the hypothesis that short inferior oblique muscles simply hold the globes in extorted positions, and the appearance of inferior oblique muscle "overaction" arises from the eyes' following their extorted movement paths on side gazes, not from hypertonicity of the inferior oblique muscle in the adducting eye. [J Pediatr Ophthalmol Strabismus. 2022;59(1):28-34.].

Accessory iris membranes: Removing the veil.

PURPOSE: To report a case of a young adult with dense bilateral accessory iris membranes (AIMs). OBSERVATIONS: AIMs can influence vision by multiple mechanisms. We discuss clinical examination and imaging considerations that can help parse optical and refractive complications to better guide intervention discussions. We also describe our surgical approach and perioperative management to help minimize trauma to the eye and maximize favorable surgical outcomes in these cases. CONCLUSIONS AND IMPORTANCE: This case highlights the excellent symptomatic, visual acuity and stereopsis gains that can be achieved following surgical intervention for this clinical entity, even in older patients.

Telemedicine utilization by pediatric ophthalmologists during the COVID-19 pandemic.

Understanding provider perspectives on telemedicine adoption during the COVID-19 pandemic can help inform best practices for delivering pediatric ophthalmic care safely and remotely. In this online survey distributed to two national pediatric ophthalmology list-servs, respondents in July-August 2020 (n = 104) compared with respondents in March-April 2020 (n = 171) were more likely to report not using and not planning on using telemedicine. The July-August respondents who did not use telemedicine were concerned about the limitations in care provided, challenges with implementation, and perceived negative effects on the doctor-patient relationship. These findings demonstrate a lack of sustained uptake of telemedicine in the first 6 months of the pandemic and concerns that should be addressed to facilitate integration of this approach in pediatric ophthalmic care.

Comparison of a New, Filter-Free Stereopsis Test (BEST) With the Randot Stereotest in a Pediatric Cohort.

PURPOSE: To evaluate the Bernell Evaluation of Stereopsis Test (BEST) (Bernell Corporation, Mishawaka, IN), a new lenticular technology and filter-free test to measure stereopsis in children, and compare it to the Randot Stereotest (Randot) (Stereo Optical, Inc., Chicago, IL). METHODS: This was a retrospective review of the medical records of children examined at the Center for Pediatric Ophthalmology at Hadassah-Hebrew University Medical Center from July to November 2018. All children were evaluated with the Randot and BEST in a random order. RESULTS: The study included 100 children (53% female, 64% orthophoric) with a mean age of 8.52 ± 3.18 years (range: 3.3 to 17.8 years) and mean best corrected visual acuity of 0.178 ± 0.16 logMAR (range: 0 to 0.7 logMAR). The mean BEST stereoacuity was 1.772 ± 0.27 log seconds of arc (arcsec), whereas the mean Randot stereo-acuity was 1.778 ± 0.39 log arcsec (P = .835). The Bland- Altman analysis revealed an overall bias of 0.0073 log arcsec (95% confidence interval: 0.04219 to 0.05679 log arcsec), with limits of agreement of -0.4816 to 0.4962 log arcsec (0.3299 to 3.1347 arcsec). A significant proportional bias was noted because the difference between the tests was significantly larger in higher log arcsec values (t = 5.566, P < .001). Age, gender, strabismus, and visual acuity did not affect the differences between the stereoacuity tests (P > .05). Both tests were influenced by strabismus but not monocular amblyopia. CONCLUSIONS: BEST stereoacuity measurements were comparable to those of the Randot, with no significant difference in crude values, minimal bias, and narrow limits of agreement. A larger, clinically insignificant variability between tests was noted with lower stereoacuity values, because children achieved better scores with the BEST. The BEST may be a valuable tool in the arsenal of the ophthalmologist. [J Pediatr Ophthalmol Strabismus. 2020;57(2):129-135.].

Using IOLs for anterior segment photography in children.

We present a novel and convenient technique for obtaining clear, high-resolution anterior segment images using an expired intraocular lens (IOL) over the lens of a smartphone's camera. Our technique provides the means to acquire high-quality images when expensive anterior segment imaging devices are unavailable. A further advantage is decreasing the economic and environmental costs of expired IOLs, whose life can be extended through "recycling" as adjunctive camera lenses.

Pediatric Acquired and Progressive Retinal Nerve Fiber Layer Myelination Following Idiopathic Intracranial Hypertension.

Few anecdotal reports have documented new onset and progression of myelination of the retinal nerve fiber layer. The authors report the unusual onset and progression of acquired myelination of the retinal nerve fiber layer in two children, following the diagnosis of presumed idiopathic intracranial hypertension. The nosologic relationship between myelination of the retinal nerve fiber layer and idiopathic intracranial hypertension is unclear and requires elucidation by further studies. [J Pediatr Ophthalmol Strabismus. 2019;56:e57-e59.].

Quantifying metamorphopsia in patients with diabetic macular oedema and other macular abnormalities.

PURPOSE: To quantify subjective visual metamorphopsia in newly diagnosed patients suffering from diabetic macular oedema (DME) and other macular abnormalities and to evaluate anti-VEGF treatment effect. METHODS: Patients with DME, subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) or retinal venous occlusion (RVO) were recruited. Metamorphopsia score (Mscore) was calculated using M-Charts at baseline and at the end of a series of anti-VEGF injections. RESULTS: Fifteen eyes of 10 patients with DME, 14 eyes of 13 patients with AMD-CNV and five patients with RVO were included in this study. At baseline, positive Mscore was observed in 46.6% of eyes with DME, 50% of eyes with AMD-CNV and four of five eyes with RVO. Treatment led to a complete metamorphopsia reduction (Mscore = 0) in 71.4% of DME patients, 35.7% of AMD and 0% of RVO patients. CONCLUSION: We suggest that the M-charts may serve as an additional test for diagnosis and follow-up, complementary to morphological evaluation by imaging, in diabetic patients facing their first anti-VEGF treatment.