PATIENTS PRESENTING EMERGENTLY WITH PROLIFERATIVE DIABETIC RETINOPATHY: Follow-up and Factors Associated With Compliance.

PURPOSE: To determine the rate of follow-up after emergent encounters for proliferative diabetic retinopathy and to identify patient or visit characteristics associated with follow-up compliance. METHODS: A retrospective cohort study of patients presenting to an ophthalmic emergency department with active proliferative diabetic retinopathy between May 2014 and December 2016 was conducted. Demographic data and encounter data were gathered for each emergency department visit. Compliance with follow-up was defined as a completed clinic visit as scheduled after the emergency encounter. RESULTS: A total of 590 emergency department encounters were included. The overall follow-up rate was 61.9%. Married patients and those with Public Health Trust insurance had increased odds of compliance (odds ratio [OR]: 1.507, P = 0.04; OR: 2.749, P < 0.0001). Patients with Medicaid had reduced odds (OR: 0.543, P = 0.004). Patients with longer emergency department encounters and longer intervals to follow-up had reduced odds (OR: 0.948, P = 0.001; OR of 0.941, P < 0.0001). The other characteristics were not significantly associated with follow-up compliance. CONCLUSION: Patients who present emergently with active proliferative diabetic retinopathy are at high risk of following up noncompliance. Characteristics with significant effects on the odds of follow-up compliance include specific insurance payer, marriage status, length of visit, and interval to follow-up.

Lessons learned: wrong intraocular lens.

OBJECTIVE: To report cases involving the placement of the wrong intraocular lens (IOL) at the time of cataract surgery where human error occurred. DESIGN: Retrospective small case series, convenience sample. PARTICIPANTS: Seven surgical cases. METHODS: Institutional review of errors committed and subsequent improvements to clinical protocols. MAIN OUTCOME MEASURES: Lessons learned and changes in procedures adapted. RESULTS: The pathways to a wrong IOL are many but largely reflect some combination of poor surgical team communication, transcription error, lack of preoperative clarity in surgical planning or failure to match the patient, and IOL calculation sheet with 2 unique identifiers. CONCLUSIONS: Safety in surgery involving IOLs is enhanced both by strict procedures, such as an IOL-specific "time-out," and the fostering of a surgical team culture in which all members are encouraged to voice questions and concerns.

Correlations Between Different Choriocapillaris Flow Deficit Parameters in Normal Eyes Using Swept Source OCT Angiography.

PURPOSE: Choriocapillaris (CC) imaging of normal eyes with swept-source optical coherence tomographic angiography (SS-OCTA) was performed, and the percentage of CC flow deficits (FD%) and the average area of CC flow deficits (FDa) were compared within the given macular regions. DESIGN: A prospective, cross-sectional study. METHODS: Subjects with normal eyes ranging in age from their 20s through their 80s were imaged with SS-OCTA (PLEX Elite 9000; Carl Zeiss Meditec, Dublin, California, USA) using both 3×3-mm and 6×6-mm macular scan patterns. The CC images were generated using a previously published and validated algorithm. In both 3×3-mm and 6×6-mm scans, the CC FD% and FDa were measured in circular regions centered on the fovea with diameters as 1 mm and 2.5 mm (C1 and C2.5). In 6×6-mm scans, the FD% and FDa were measured within an additional circular region with diameter as 5 mm (C5). The correlations between FD% and FDa from each region were analyzed with Pearson correlation coefficients. RESULTS: A total of 164 eyes were analyzed. There was excellent correlation between CC FDa and FD% measurements from each region. In the 3×3-mm scans, the correlations in the C1 and C2.5 regions were 0.83 and 0.90, respectively. In the 6×6-mm scans, the correlations in C1, C2.5, and C5 regions were 0.90, 0.89, and 0.89, respectively. CONCLUSIONS: When measuring CC FDs, we found excellent correlations between FDa and FD% in regions from 3×3-mm and 6×6-mm scans. Further studies are needed to determine if one parameter is more useful when studying diseased eyes.

Age-dependent Changes in the Macular Choriocapillaris of Normal Eyes Imaged With Swept-Source Optical Coherence Tomography Angiography.

PURPOSE: Swept-source optical coherence tomography angiography (SS-OCTA) was used to measure the age-dependent changes in macular choriocapillaris (CC) flow deficits (FDs) in normal eyes. DESIGN: A prospective, cross-sectional study. METHODS: Subjects with normal eyes ranging in age from their 20s to their 80s were imaged using a 100-kHz SS-OCTA instrument (PLEX Elite 9000, Carl Zeiss Meditec, Dublin, California, USA). Both 3 × 3-mm and 6 × 6-mm scans were used to image the macular CC. Visualization of the CC and quantification of FDs were performed using a previously validated algorithm. The percentage of FDs (FD%) in the central 1-mm circle (C1), 1.5-mm rim (R1.5), and 2.5-mm circle (C2.5) from the 3 × 3-mm and 6 × 6-mm scans and FD% in the 2.5-mm rim (R2.5) and 5-mm circle (C5) from the 6 × 6-mm scans were measured and correlated with age and axial length. RESULTS: A total of 164 subjects were enrolled, with at least 10 subjects from each decade of life. No meaningful correlations were found between FD% and axial length (|r| < 0.30). FD% in all fields increased with increasing age (all r > 0.50; all P < .001); however, the greatest increases were found in the central macula C1 regions and the smallest increases in the peripheral macula R2.5 regions. CONCLUSIONS: In normal aging, the FD% increased with age across the central 5 mm of the macula, but the greatest increase was found in the central 1-mm region of the macula.

Utilization of Ophthalmology-Specific Emergency Department Services.

OBJECTIVE: To describe utilization trends of an ophthalmology-specific emergency department (ED). METHODS: Prospective cohort study of new patients presenting in the ophthalmology ED for at least a 30-day period in the spring of each year for five consecutive years (2010-14) at a university referral center. A data form, including information about the ED visit and patient demographics, was included in each patient chart. Data were analyzed with Pearson chi-square test and multiple logistic regression. RESULTS: A total of 5323 chart data forms were completed. An average of 42.2 new patients per day presented to the ophthalmology ED. Most common diagnoses were viral conjunctivitis (8.7%), dry eye syndrome (6.6%), and corneal abrasion (6.6%). Non-emergent visits accounted for 35.8% of surveys completed. Factors associated with non-emergent visits included female gender, age 65 years or older, weekday visits, and patient symptom duration greater than one week (p < 0.0001 for each factor). When compared to all other insurance categories combined, patients who were members of the regional public assistance program were the most likely to present with a non-emergency (48.5% versus 34.9%, p < 0.001), while Workers' Compensation patients were least likely to present with a non-emergency (16% versus 36.5%, p < 0.001). CONCLUSIONS: Over one-third of new patient visits were non-emergent. Factors predictive of non-emergent patient visits were female gender, age 65 years or older, duration of symptoms greater than one week, weekday visits, and the form of insurance coverage.

Wavefront Derived Refraction and Full Eye Biometry in Pseudophakic Eyes.

PURPOSE: To assess wavefront derived refraction and full eye biometry including ciliary muscle dimension and full eye axial geometry in pseudophakic eyes using spectral domain OCT equipped with a Shack-Hartmann wavefront sensor. METHODS: Twenty-eight adult subjects (32 pseudophakic eyes) having recently undergone cataract surgery were enrolled in this study. A custom system combining two optical coherence tomography systems with a Shack-Hartmann wavefront sensor was constructed to image and monitor changes in whole eye biometry, the ciliary muscle and ocular aberration in the pseudophakic eye. A Badal optical channel and a visual target aligning with the wavefront sensor were incorporated into the system for measuring the wavefront-derived refraction. The imaging acquisition was performed twice. The coefficients of repeatability (CoR) and intraclass correlation coefficient (ICC) were calculated. RESULTS: Images were acquired and processed successfully in all patients. No significant difference was detected between repeated measurements of ciliary muscle dimension, full-eye biometry or defocus aberration. The CoR of full-eye biometry ranged from 0.36% to 3.04% and the ICC ranged from 0.981 to 0.999. The CoR for ciliary muscle dimensions ranged from 12.2% to 41.6% and the ICC ranged from 0.767 to 0.919. The defocus aberrations of the two measurements were 0.443 ± 0.534 D and 0.447 ± 0.586 D and the ICC was 0.951. CONCLUSIONS: The combined system is capable of measuring full eye biometry and refraction with good repeatability. The system is suitable for future investigation of pseudoaccommodation in the pseudophakic eye.

Presumed toxoplasmosic anterior optic neuropathy.

PURPOSE: To describe the clinical findings and course of toxoplasmic anterior optic neuropathy and to differentiate primary and secondary involvement. METHODS: Retrospective observational case series from a tertiary referral institution. Clinical and photographic charts of 13 patients with toxoplasmosis with direct optic nerve head involvement were reviewed and data were collected throughout the length of follow-up. RESULTS: Toxoplasmic anterior optic neuropathy was divided into two types. Type I was defined as secondary infectious involvement of the optic nerve head from an adjacent focus of chorioretinitis that resolved with chorioretinal scarring. Type II was defined as primary involvement of the optic nerve head that resolved without chorioretinal scarring. Visual acuity improved after treatment in both Type I and Type II patients; however, the visual prognosis was worse in Type I patients due to macular involvement. Eighty-three percent of Type II patients had a final visual acuity equal to or better than 20/25 compared to 50% of Type I patients. Visual field defects were present in all patients, most frequently arcuate or altitudinal (62%). Delay in diagnosis was common (54%), especially in Type II patients (71%). Vitreous inflammation was absent on the initial examination in 31% of the patients. CONCLUSION: Toxoplasmic anterior optic neuropathy is an uncommon manifestation of ocular toxoplasmosis. Delays in diagnosis are common because of the frequent lack of typical chorioretinitis or vitreous inflammation. Adjacent macular involvement strongly influences visual outcome.

Cholesterol and glycosphingolipids of human trabecular meshwork and aqueous humor: comparative profiles from control and glaucomatous donors.

PURPOSE: To determine the differential profiles of cholesterol and glycosphingolipid species and their quantitative differences between control and glaucomatous aqueous humor (AQH) and the trabecular meshwork (TM) derived from human donors. METHODS: Control TM and selected primary open angle glaucoma (POAG) TM samples were collected from cadaveric donors. Other TM samples, glaucomatous AQH and control AQH were procured during intraocular surgery. Lipid extraction was performed using modifications of the Bligh and Dyer method. Protein concentration was estimated using the Bradford colorimetric assay. Cholesterol and glycosphingolipids were identified and subjected to ratiometric quantification utilizing precursor ion scan and neutral ion loss scan in positive ion mode using appropriate class specific lipid standards (Cholesterol and Psychosine) on a TSQ Quantum Access Max mass spectrometer. RESULTS: Control and glaucomatous AQH demonstrated 7 and 4 unique cholesterol species, whereas the TM demonstrated 7 and 12 unique species, respectively. The control and POAG AQH showed 6 and 0 whereas TM samples showed 5 and 1 unique glycosphingolipids, respectively. A total of 65 and 62 common cholesterol species and 59 and 58 common glycosphingolipids were found in AQH and TM, respectively. Increased zymosterol and glucopyranosyl cholesterol levels were found in glaucomatous AQH. Significantly decreased levels of galactosylceramide, glucosylceramide in glaucomatous TM were found compared to control TM. CONCLUSION: A high percentage of cholesterol and glycosphingolipid species was found to be common between control and POAG AQH and TM. Several cholesterol and glycosphingolipid species was found to be unique in a subset of POAG or controls. Glaucomatous aqueous humor and TM showed relatively higher levels of zymosterol (an intermediate precursor of cholesterol) and decreased glycoceramide levels, respectively.

Post-streptococcal vasculitis.

PURPOSE: To report a case of post-streptococcal retinal vasculitis. DESIGN: Review of a case. METHODS: Review of patient chart and fluorescein angiography. RESULTS: A 17 year old African American female presented with moderate vitritis and macular edema in the right eye and retinal vessel sheathing in both eyes. CONCLUSIONS: Although CNS vasculitis is well recognized as a post-streptococcal syndrome, this case illustrates that retinal vasculitis can also occur in this setting, and can resolve with oral steroid therapy.