Biomarkers of Pediatric Cataracts: A Proteomics Analysis of Aqueous Fluid.

Cataracts are among the most common causes of childhood vision loss worldwide. This study seeks to identify differentially expressed proteins in the aqueous humor of pediatric cataract patients. Samples of aqueous humor were collected from pediatric and adult cataract patients and subjected to mass spectrometry-based proteomic analysis. Samples of pediatric cataracts were grouped by subtype and compared to adult samples. Differentially expressed proteins in each subtype were identified. Gene ontology analysis was performed using WikiPaths for each cataract subtype. Seven pediatric patients and ten adult patients were included in the study. Of the pediatric samples, all seven (100%) were male, three (43%) had traumatic cataracts, two (29%) had congenital cataracts, and two (29%) had posterior polar cataracts. Of the adult patients, seven (70%) were female and seven (70%) had predominantly nuclear sclerotic cataracts. A total of 128 proteins were upregulated in the pediatric samples, and 127 proteins were upregulated in the adult samples, with 75 proteins shared by both groups. Gene ontology analysis identified inflammatory and oxidative stress pathways as upregulated in pediatric cataracts. Inflammatory and oxidative stress mechanisms may be involved in pediatric cataract formation and warrant further investigation.

Leukemic and Lymphomatous Optic Neuropathy: A Case Series.

BACKGROUND: Optic neuropathy in the context of leukemia and lymphoma raises concern for central nervous system involvement or relapse and warrants prompt evaluation and treatment. To date, a gold standard for the diagnosis and management of leukemic optic neuropathy has yet to be established. METHODS: Case series and review of the literature. Two illustrative cases were selected to discuss their treatment course and outcome. RESULTS: We report 7 cases of patients with leukemia or lymphoma presenting with optic nerve infiltration. All patients received steroid therapy for presumed infiltrative optic neuropathy, and 4 patients underwent radiation therapy. Along with systemic chemotherapy, all patients received intrathecal chemotherapy except one. Three patients received chimeric antigen receptor T-cell therapy. CONCLUSIONS: Leukemic and lymphomatous optic neuropathy is difficult to diagnose and treat, and there is no gold standard for diagnosis or treatment in the current literature. We help clarify how this disease should be approached in a multidisciplinary fashion and on an individual basis to correctly diagnose and treat the vision loss, while considering the patient's long-term prognosis based on their systemic disease.

Fuchs Endothelial Corneal Dystrophy: Update on Pathogenesis and Future Directions.

Fuchs endothelial corneal dystrophy (FECD) is the most common indication for corneal transplantation in the United States, accounting 36% of the almost 47,000 transplants performed in 2016. Although the surgical management of FECD has undergone a revolution over the past 20 years, its pathogenesis remains elusive, with multiple putative disease pathways and an ever increasing number of candidate genes thought to play a role. This review will summarize the recent advancements in our understanding of the biology of FECD, including potential parallels with neurodegenerative disease like amyotrophic lateral sclerosis and will highlight prospects for future treatment advances.

Medial Orbital Wall Reconstruction to Facilitate Endoscopic Sinus Surgery for Erosive Polypoidal Sinus Disease.

The authors report the use of a 0.35-mm-thickness nylon implant for medial orbital wall reconstruction to facilitate functional endoscopic sinus surgery (FESS) for severe erosive polypoidal sinus disease while minimizing iatrogenic injuries to the orbital contents. A retrospective chart review identified 4 patients with extensive polypoidal sinus disease who underwent medial orbital wall reconstruction in the setting of FESS. All patients underwent successful reconstruction of bilateral eroded medial orbital walls using a 0.35-mm Supramid Foil Nylon Implant immediately followed by FESS. There were no permanent complications or iatrogenic injuries to the orbital contents due to FESS. All patients experienced improvement in sinus symptoms. Medial orbital wall reconstruction in the setting of erosive polypoidal sinus disease is a useful tool to help facilitate FESS. It allows the sinus surgeon to clear sinus disease aggressively with the orbits being protected from iatrogenic injury.

Toxic Keratoconjunctivitis.

Toxic keratoconjunctivitis (TK) is an underrecognized complication of ophthalmic drug use and various environmental or occupational exposures. A detailed history and clinical examination are important to identify the offending agent(s). Common drug-related causes of TK include preservatives in ophthalmic medications, topical antimicrobials, and topical anesthetics. Alternatives to benzalkonium chloride as well as preservative-free formulations should be considered in patients requiring long-term topical medication. More advanced cases of TK may require preservative-free topical steroids and/or antibiotics, and occasionally surgical intervention. Early recognition and appropriate management of TK may help prevent permanent ocular and visual damage.

Biofilm Formation on Bandage Contact Lenses Worn by Patients with the Boston Type 1 Keratoprosthesis: A Pilot Comparison Study of Prophylactic Topical Vancomycin 15 mg/mL and Linezolid 0.2.

OBJECTIVES: To determine the rate of biofilm formation on bandage contact lenses worn by patients with the Boston type 1 keratoprosthesis (K-Pro) while on prophylactic topical vancomycin versus linezolid. METHODS: Patients wearing a bandage contact lens (BCL) with a K-Pro were eligible for enrollment. After irrigation of the ocular surface with 5% povidone-iodine solution, each patient was placed on either topical vancomycin 15 mg/mL or linezolid 0.2% BID for one month. At the one-month visit, the BCL was collected and stored in fixative solution. Standard photographs were taken of each lens at high magnification using scanning electron microscopy (SEM), which were subsequently analyzed for evidence of biofilm. RESULTS: Nineteen contact lenses were obtained from 12 K-Pro patients at the Illinois Eye and Ear Infirmary. Zero of eight (0%; 95% CI=0 to 37%) contact lenses from patients treated with topical vancomycin, and 1 of 11 (9%; 95% CI=0 to 41%; P-value=1.00) contact lenses from patients treated with topical linezolid were found to have biofilm formation at one month as detected by SEM. None of the patients developed a clinically significant infection while on either prophylactic vancomycin or linezolid during the study period. CONCLUSIONS: Overall, the rate of biofilm formation as detected by SEM on the surface of bandage contact lenses was low. These results suggest that vancomycin and linezolid are both relatively effective in reducing biofilm-forming bacterial growth at one month. Accordingly, linezolid may be an effective alternative to vancomycin in patients with allergy or intolerance. However, further investigation is required to develop evidence-based antibiotic prophylaxis regimens.

Infections after refractive surgery.

PURPOSE OF REVIEW: The purpose of the review is to provide a summary of the recent literature concerning infections after refractive surgery pertinent to each procedure category. RECENT FINDINGS: New data from a large retrospective study suggest that the incidence of post-laser assisted in-situ keratomileusis infectious keratitis is declining. Additionally, recent case studies have reported viral, fungal, and Acanthamoeba pathogens. Corneal collagen cross-linking is emerging as an alternative therapeutic option for early stage post-LASIK infectious keratitis. Postoperative bandage contact lens used in patients undergoing surface ablation procedures may confer a higher risk of infection because of greater colonization rates in those individuals, such as healthcare providers, with relatively high risk of exposure to potential pathogens. In the setting of post-penetrating keratoplasty astigmatism, femtosecond laser astigmatic keratotomy procedures pose a risk of infectious keratitis and even endophthalmitis. Lastly, recent case reports of endophthalmitis after refractive lens procedures highlight the importance of postoperative monitoring for this sight threatening, albeit rare, complication. SUMMARY: The risks and management of infections after surgical refractive procedures vary widely depending on the specific technique employed. As technology and treatment options continue to evolve with further research, we anticipate continued success in the management of postoperative infections after refractive surgery.

Fungal Orbital Cellulitis: Presenting Features, Management and Outcomes at a Referral Center.

PURPOSE: To report a series of patients with fungal orbital cellulitis who underwent exenteration surgery and describe presenting features, management and outcomes at a referral center. METHODS: Retrospective case series. RESULTS: From November 2011 to March 2014, four patients underwent orbital exenteration for fungal orbital cellulitis at the University of Illinois. Three patients had mucormycosis and one had aspergillosis. All patients were treated with intravenous antifungals and underwent orbital exenteration. Two patients were successfully treated with supplemental intra-orbital catheter delivery of amphotericin B. Presenting visual acuity in the affected eye ranged from 20/25 to no light perception. Some level of ophthalmoplegia was present in three patients. Significantly elevated intraocular pressure was found in two patients. All patients with mucormycosis were found to have uncontrolled diabetes mellitus. One patient had a history of myelodysplastic syndrome, chronic hepatitis C infection, polysubstance abuse and Crohn's disease. Another patient had a history of alcoholic liver cirrhosis, Crohn's disease treated with systemic immunosuppression and renal cell carcinoma. The patient with aspergillosis had myelodysplastic syndrome and portal hypertension, and the initial presentation resembled giant cell arteritis. Two of four patients died during their hospitalization. CONCLUSIONS: Fungal orbital cellulitis has a high mortality rate despite aggressive antifungal treatment and orbital exenteration performed soon after the diagnosis is confirmed. Patients often have a history of immunosuppression and the onset may be insidious. There must be a high rate of suspicion for fungal orbital cellulitis given the appropriate signs and medical history in order to avoid treatment delay.

Alternating skew deviation in association with anti-glutamic acid decarboxylase antibodies.

The presence of an elevated anti-glutamic acid decarboxylase (GAD) antibody level has been associated with a number of eye movement abnormalities, as well as other findings including cerebellar ataxia and insulin dependent diabetes mellitus. Skew deviation in association with anti-GAD antibodies has not been previously reported. Here we report a case of alternating skew deviation along with cerebellar-brainstem signs in a patient with an elevated anti-GAD antibody titer. Follow-up neurologic evaluation after treatment with intravenous immunoglobulin revealed improvement in cerebellar-brainstem signs, while ophthalmic evaluation was stable.

Noninfectious Outcomes of Intravitreal Antibiotic Steroid Injection and Topical Nonsteroidal Antiinflammatory Drugs Versus Triple Drop Therapy After Cataract Surgery.

PURPOSE: To compare noninfectious outcomes of intravitreal antibiotic steroid (IVAS) injection (moxifloxacin-triamcinolone) and postoperative topical nonsteroidal antiinflammatory drugs (NSAID) with a standard 3-drop therapy (TDT) regimen (topical antibiotic, steroid, and NSAID) in patients after cataract surgery. DESIGN: Retrospective comparative clinical cohort study. METHODS: In 3 study centers in the United States, a total of 2143 eyes (N = 2143 patients) underwent cataract surgery with IVAS-NSAID or TDT between 2017 and 2022. Preoperative data were included, including patients' age, iris color, medical history, and ocular history. Postoperative data, including best-corrected visual acuity, intraocular pressure (IOP), and the need for IOP-lowering medications, were recorded at 1-week, 1-month, and 6-month time points. The primary outcome measures were postoperative complications, defined as persistent anterior chamber inflammation, persistent corneal edema (PCE), rebound inflammation, and cystoid macular edema, were compared between the 2 groups. RESULTS: There were 1079 eyes in the IVAS-NSAID group and 1064 eyes in the TDT group. Best-corrected visual acuity and IOP were similar between IVAS-NSAID and TDT eyes at all time points. A portion (11.6%) of TDT eyes experienced postoperative complications compared with 6.5% in IVAS-NSAID eyes (P < .001). Femtosecond laser-assisted cataract surgery was associated with increased rates of PCE in IVAS-NSAID eyes, and eyes with dark irides had a higher incidence of cystoid macular edema, PCE, and rebound inflammation in the IVAS-NSAID group. CONCLUSION: The IVAS-NSAID regimen overall had similar postoperative outcomes and fewer complications compared with the TDT regimen. IVAS-NSAID may be considered a safe alternative to topical regimens in non-femtosecond laser-assisted cataract surgery and patients with light irides.

Incidence and Mitigation of Corneal Pseudomicrocysts Induced by Antibody-Drug Conjugates (ADCs).

Purpose of Review: This study is to highlight the incidence of corneal pseudomicrocysts in FDA-approved antibody-drug conjugates (ADCs), and success of preventive therapies for pseudomicrocysts and related ocular surface adverse events (AEs). Recent Findings: ADCs are an emerging class of selective cancer therapies that consist of a potent cytotoxin connected to a monoclonal antibody (mAb) that targets antigens expressed on malignant cells. Currently, there are 11 FDA-approved ADCs with over 164 in clinical trials. Various AEs have been attributed to ADCs, including ocular surface AEs (keratitis/keratopathy, dry eye, conjunctivitis, blurred vision, corneal pseudomicrocysts). While the severity and prevalence of ADC-induced ocular surface AEs are well reported, the reporting of corneal pseudomicrocysts is limited, complicating the development of therapies to prevent or treat ADC-related ocular surface toxicity. Summary: Three of 11 FDA-approved ADCs have been implicated with corneal pseudomicrocysts, with incidence ranging from 41 to 100% of patients. Of the six ADCs that reported ocular surface AEs, only three had ocular substudies to investigate the benefit of preventive therapies including topical steroids, vasoconstrictors, and preservative-free lubricants. Current preventive therapies demonstrate limited efficacy at mitigating pseudomicrocysts and other ocular surface AEs.

Ocular Injuries From Drive-by Paintball Shootings.

PURPOSE: To characterize ocular injuries from drive-by paintball shootings with a focus on the severity of injuries sustained, clinical management, and visual outcomes. DESIGN: Retrospective, interventional case series. METHODS: Setting: University practice and emergency department. PATIENT POPULATION: Patients evaluated by the ophthalmology service for paintball injuries. OBSERVATION PROCEDURE: Age, sex, eye laterality, mechanism of injury, initial best-corrected visual acuity (BCVA), and initial diagnosis. MAIN OUTCOME MEASURES: Clinical intervention(s), BCVA at last follow-up visit, and severity of injuries with a focus on ruptured globes. RESULTS: Twenty patients suffered unilateral ocular injuries from drive-by paintball shootings between January 2020 and December 2021. The median follow-up interval was 7.1 weeks (range: 3 days to 11.4 months). The average patient age at presentation was 36.6 years (range: 13-64 years). Fourteen patients (70%) had an initial BCVA of counting fingers or worse. Six patients (30%) suffered a ruptured globe injury requiring surgical repair, of whom 3 (15%) underwent subsequent evisceration. Twelve patients (60%) suffered ocular injuries requiring surgical intervention. Fifteen ocular surgeries were performed on 9 patients (45%) at our institution with 3 patients referred to outside providers for definitive surgical management due to insurance. BCVA at last follow-up visit was no light perception in 5 patients. CONCLUSIONS: The severity of injury after paintball-induced ocular trauma is higher in this case series than what has previously been reported in the literature. Paintball guns can cause devastating ocular injury when used as an assault weapon, and their use in unregulated settings bears further scrutiny.

Atypical Keratitis Caused by Rothia Dentocariosa.

Purpose: To report a case of atypical keratitis caused by Rothia dentocariosa.Methods: Retrospective case review.Results: A 49 year-old woman of South Asian descent presented with a non-discrete corneal ulcer with a small overlying epithelial defect in the right eye. Cultures were obtained, a topical fluoroquinolone was continued, and a topical steroid was added. The following day, the infiltrate was noted to have worsened and developed a branching appearance. Antifungals were initiated. The culture grew Rothia dentocariosa. A series of intrastromal cefuroxime injections, followed by topical penicillin G drops, led to complete resolution within 8 weeks. A review of the literature revealed only one previously reported case of Rothia dentocariosa keratitis.Conclusions: Rothia dentocariosa may cause an atypical keratitis requiring a prolonged treatment course for resolution. In our case, a combination of cefuroxime and penicillin was effective.

Severe Corneal Hydrops With Suspected Posterior Stromal Rupture Managed With Ultrathin Descemet-Stripping Automated Endothelial Keratoplasty.

PURPOSE: To describe severe acute corneal hydrops in a patient with previously undiagnosed keratoconus, in which anterior segment optical coherence tomography (AS-OCT) revealed a protruding ridge of tissue on either side of Descemet membrane (DM) break, treated successfully with ultrathin Descemet-stripping automated endothelial keratoplasty (UT-DSAEK). METHODS: A case report. RESULTS: A 32-year-old man presented with severe corneal hydrops in OS. He was treated conservatively with hypertonic saline. Serial AS-OCT revealed persistent edema and haze overlying a break in DM, with a ridge of protruding tissue on either side. Based on these findings, UT-DSAEK was performed. Intraoperatively, the ridge of tissue remained firmly adhered after DM removal and was felt to possibly represent posterior stroma. The patient's uncorrected visual acuity improved to 20/80. Literature review revealed 1 case with similar AS-OCT findings who underwent penetrating keratoplasty; histopathology was reported to show Descemet scrolls on either side of the break, but our analysis of this and other reports suggest that an additional layer of tissue is contained within the scroll along with DM. CONCLUSIONS: This case demonstrates severe corneal hydrops in the setting of keratoconus, in which AS-OCT revealed a ridge of protruding tissue on either side of a break in DM. UT-DSAEK led to resolution of corneal edema and improvement in stromal haze and visual acuity. Further research is required to determine the precise role of endothelial keratoplasty and potential role of posterior stromal rupture in some cases of acute corneal hydrops.

Management of severe epithelial versus fibrous downgrowth following trabeculectomy: Case report and literature review.

PURPOSE: To describe the presentation and management of a patient with epithelial versus fibrous downgrowth following trabeculectomy surgery and review relevant literature regarding this complication after intraocular surgery. OBSERVATIONS: A 52-year-old monocular African-American woman was referred for management of presumed epithelial versus fibrous downgrowth following trabeculectomy surgery. The patient was initially treated with intracameral injections of 5-fluorouracil (x2) and bevacizumab (x1). Cataract extraction, membranectomy, and a third intracameral 5-fluorouracil injection were performed. Intraocular pressure (IOP) elevation was subsequently managed with a superotemporal Ahmed FP7 glaucoma drainage device in the sulcus, followed by an inferonasal Baerveldt 350 glaucoma drainage device in the sulcus. The downgrowth has not progressed and the intraocular pressure remains controlled at the most recent follow-up. CONCLUSIONS: This case underscores the risk of this complication following trabeculectomy, the role of a combined medical and surgical approach to management, and the possible need for multiple surgical interventions to control IOP. A review of the literature regarding epithelial and fibrous downgrowth after intraocular surgery was conducted, which highlighted the aggressive nature of these conditions and the range of therapeutic approaches that have been described.

Refractive and keratometric outcomes of supervised novice surgeon-performed limbal relaxing incisions: 1-year results.

PURPOSE: To report refractive and keratometric astigmatism outcomes of resident-performed limbal relaxing incisions (LRIs) during cataract surgery. SETTING: Tertiary care academic teaching hospital. DESIGN: Retrospective case series. METHODS: The length, location, and number of LRIs were determined preoperatively using an online calculator. Variables studied were preoperative keratometry and postoperative uncorrected and corrected distance visual acuity, refraction, and keratometry at 1-month, 3-month, and 12-month visits (POM1, POM3, and POM12, respectively). Subgroup analysis was performed on amount and type of astigmatism. The astigmatism double-angle plot tool and analysis of with-the-wound (WtW) and against-the-wound (AtW) changes were used to assess the effect of astigmatism correction at POM1, POM3, and POM12 visits. RESULTS: In 118 eyes, a higher percentage of eyes demonstrated refractive astigmatism 0.25 diopter (D) or less, 0.50 D or less, 0.75D or less, and 1.0 D or less at POM1 and POM12 (all P < .05) compared with preoperative keratometric astigmatism. Subgroup analysis showed improvement in all groups and types of astigmatism (P < .01). Patients achieved a statistically significant reduction of keratometric astigmatism at POM1, POM3, and POM12 (all P ≤ .0001) relative to baseline, and changes differed significantly based on the preoperative amount of astigmatism (all P ≤ .0001, with greater reductions associated with higher baseline astigmatism) but not by location of the steep meridian. There were significant WtW-AtW changes at POM1, POM3, and POM12. Regression of effect after 1 month was approximately 0.11 D. CONCLUSIONS: Resident-performed LRIs achieved effective and sustained reduction of both refractive and keratometric astigmatism regardless of meridian or magnitude of astigmatism for at least 1 year postoperatively.

Aftermarket effects of cenegermin for neurotrophic keratopathy in pediatric patients.

PURPOSE: Neurotrophic keratopathy (NK) is a rare condition characterized by poor corneal sensation and healing. Cenegermin (topical recombinant nerve growth factor) has gained traction as a medical therapy for NK in recent years, and is FDA-approved for patients over two years old. However, no major trials have demonstrated the drug's efficacy in children. This study reviews the outcomes of cenegermin therapy in a pediatric patient population. METHODS: Retrospective case series of patients from three tertiary referral institutions who 1) initiated an 8-week course of cenegermin therapy, and 2) were 18 years or less at time of treatment initiation. RESULTS: Eight pediatric patients, with a total of nine affected eyes, underwent cenegermin therapy. All eight patients had previously trialed other NK-specific treatments, none of which had been entirely successful. Five patients (63%) completed the full eight-week therapy course. Five patients (63%) experienced clinical improvement not attributed to another treatment, through improved corneal ulcer stage (n = 5) and best-corrected visual acuity (n = 2). Clinical improvements persisted through a mean recurrence-free period of 10 months. Adverse effects reported during therapy included ocular pain, difficulty sleeping, and continued corneal thinning. CONCLUSION: The results provide modest support for the use of cenegermin in pediatric patients with neurotrophic keratopathy. The primary benefit was an improvement in corneal epithelial stability. Clinicians should be aware that pre-existing corneal scarring in NK may significantly limit the ability of cenegermin alone to improve visual acuity, and should closely monitor the corneal epithelial status during therapy in pediatric patients.