Pars plana vitrectomy with internal limiting membrane flap versus pars plana vitrectomy with conventional internal limiting membrane peeling for large macular hole.

BACKGROUND: Macular hole (MH) is a full-thickness defect in the central portion of the retina that causes loss of central vision. According to the usual definition, a large MH has a diameter greater than 400 µm at the narrowest point. For closure of MH, there is evidence that pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling achieves better anatomical outcomes than standard PPV. PPV with ILM peeling is currently the standard of care for MH management; however, the failure rate of this technique is higher for large MHs than for smaller MHs. Some studies have shown that the inverted ILM flap technique is superior to conventional ILM peeling for the management of large MHs. OBJECTIVES: To evaluate the clinical effectiveness and safety of pars plana vitrectomy with the inverted internal limiting membrane flap technique versus pars plana vitrectomy with conventional internal limiting membrane peeling for treating large macular holes, including idiopathic, traumatic, and myopic macular holes. SEARCH METHODS: The Cochrane Eyes and Vision Information Specialist searched CENTRAL, MEDLINE, Embase, two other databases, and two trials registries on 12 December 2022. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that evaluated PPV with ILM peeling versus PPV with inverted ILM flap for treatment of large MHs (with a basal diameter greater than 400 µm at the narrowest point measured by optical coherence tomography) of any type (idiopathic, traumatic, or myopic). DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane and assessed the certainty of the body of evidence using GRADE. MAIN RESULTS: We included four RCTs (285 eyes of 275 participants; range per study 24 to 91 eyes). Most participants were women (63%), and of older age (range of means 59.4 to 66 years). Three RCTs were single-center trials, and the same surgeon performed all surgeries in two RCTs (the third single-center RCT did not report the number of surgeons). One RCT was a multicenter trial (three sites), and four surgeons performed all surgeries. Two RCTs took place in India, one in Poland, and one in Mexico. Maximum follow-up ranged from three months (2 RCTs) to 12 months (1 RCT). No RCTs reported conflicts of interest or disclosed financial support. All four RCTs enrolled people with large idiopathic MHs and compared conventional PPV with ILM peeling versus PPV with inverted ILM flap techniques. Variations in technique across the four RCTs were minimal. There was some heterogeneity in interventions: in two RCTs, all participants underwent combined cataract-PPV surgery, whereas in one RCT, some participants underwent cataract surgery after PPV (the fourth RCT did not mention cataract surgery). The critical outcomes for this review were mean best-corrected visual acuity (BCVA) and MH closure rates. All four RCTs provided data for meta-analyses of both critical outcomes. We assessed the risk of bias for both outcomes using the Cochrane risk of bias tool (RoB 2); there were some concerns for risk of bias associated with lack of masking of outcome assessors and selective reporting of outcomes in all RCTs. All RCTs reported postoperative BCVA values; only one RCT reported the change in BCVA from baseline. Based on evidence from the four RCTs, it is unclear if the inverted ILM flap technique compared with ILM peeling reduces (improves) postoperative BCVA measured on a logarithm of the minimum angle of resolution (logMAR) chart at one month (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.20 to 0.05; P = 0.23, I2 = 65%; 4 studies, 254 eyes; very low-certainty evidence), but it may improve BCVA at three months or more (MD -0.17 logMAR, 95% CI -0.23 to -0.10; P < 0.001, I2 = 0%; 4 studies, 276 eyes; low-certainty evidence). PPV with an inverted ILM flap compared to PPV with ILM peeling probably increases the proportion of eyes achieving MH closure (risk ratio [RR] 1.10, 95% CI 1.02 to 1.18; P = 0.01, I2 = 0%; 4 studies, 276 eyes; moderate-certainty evidence) and type 1 MH closure (RR 1.31, 95% CI 1.03 to 1.66; P = 0.03, I² = 69%; 4 studies, 276 eyes; moderate-certainty evidence). One study reported that none of the 38 participants experienced postoperative retinal detachment. AUTHORS' CONCLUSIONS: We found low-certainty evidence from four small RCTs that PPV with the inverted ILM flap technique is superior to PPV with ILM peeling with respect to BCVA gains at three or more months after surgery. We also found moderate-certainty evidence that the inverted ILM flap technique achieves more overall and type 1 MH closures. There is a need for high-quality multicenter RCTs to ascertain whether the inverted ILM flap technique is superior to ILM peeling with regard to anatomical and functional outcomes. Investigators should use the standard logMAR charts when measuring BCVA to facilitate comparison across trials.

Current Management of Subretinal Hemorrhage in Neovascular Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) is the leading cause of irreversible vision loss among individuals aged 65 years and older in the USA. For individuals diagnosed with AMD, approximately 12% experience varying levels of subretinal hemorrhage (SRH), which can be further classified by size into small, medium, and massive measured in disc diameters. SRH is an acute and rare sight-threatening complication characterized by an accumulation of blood under the retina arising from the choroidal or retinal circulation. Released iron toxins, reduced nutrient supply, fibrin meshwork contraction, and outer retinal shear forces created by SRH contribute to visual loss, macular scarring, and photoreceptor damage. SRH treatment strategies aim to displace hemorrhage from the foveal region and prevent further bleeding. Although there are no standardized treatment protocols for SRH, several surgical and nonsurgical therapeutical approaches may be employed. The most common surgical approaches that have been utilized are pars plana vitrectomy (PPV) combined with multiple maneuvers such as the removal of choroidal neovascularization lesions, macular translocation, retinal pigment epithelium patch repair, SRH drainage, intravitreal injection of recombinant-tissue plasminogen activator (tPA), expansile gas and air displacement, and anti-vascular endothelial growth factor (anti-VEGF) injections. Nonsurgical therapeutical approaches include intravitreal anti-VEGF monotherapy, intravitreal tPA administration without PPV, and photodynamic therapy. This review article aims to explore the current treatment strategies and supporting literature regarding both surgical and nonsurgical, of SRH in patients with AMD. Moreover, this article also aims to highlight the distinct treatment modalities corresponding to different sizes of SRH.

Artificial intelligence and ophthalmic surgery.

PURPOSE OF REVIEW: Artificial intelligence and deep learning have become important tools in extracting data from ophthalmic surgery to evaluate, teach, and aid the surgeon in all phases of surgical management. The purpose of this review is to highlight the ever-increasing intersection of computer vision, machine learning, and ophthalmic microsurgery. RECENT FINDINGS: Deep learning algorithms are being applied to help evaluate and teach surgical trainees. Artificial intelligence tools are improving real-time surgical instrument tracking, phase segmentation, as well as enhancing the safety of robotic-assisted vitreoretinal surgery. SUMMARY: Similar to strides appreciated in ophthalmic medical disease, artificial intelligence will continue to become an important part of surgical management of ocular conditions. Machine learning applications will help push the boundaries of what surgeons can accomplish to improve patient outcomes.

Incorporating a virtual curriculum into ophthalmology education in the coronavirus disease-2019 era.

PURPOSE OF REVIEW: The purpose of this review is to describe the transition of ophthalmology education to a virtual curriculum during the COVID-19 pandemic. We highlight innovative solutions ophthalmic educators implemented for medical students, residents, and fellows. RECENT FINDINGS: Clinical and surgical ophthalmology volume abruptly decreased in March 2020 as a result of the COVID-19 public health crisis. All didactics, grand rounds, and journal clubs shifted to an online format. Ophthalmic educators collaborated with other institutions in the United States and abroad on shared virtual curricula and seminars, and simulation-based training tools were better emphasized for surgical skill acquisition. We share the latest literature written by ophthalmic educators on successful adaptation of these new instructional strategies. SUMMARY: The COVID-19 pandemic transformed ophthalmology education overnight and accelerated the adoption of innovative e-virtual learning resources for trainees. These changes will undoubtedly remain part of the new paradigm of medical education in the post-COVID era.

Dacryolithiasis: A Review.

PURPOSE: To review and summarize the clinical features, presentations, diagnostic modalities and management of dacryolithiasis. METHODS: A comprehensive PubMed search of all English articles on dacryolithiasis was reviewed. Although this review primarily relied on articles written in English, non-English-language articles that had abstracts translated into English were also reviewed. Data reviewed included epidemiology, pathogenesis, appearance and composition, clinical features, presentations, diagnostic modalities, management of dacryolithiasis and the implications of incidental dacryoliths found during lacrimal surgery. RESULTS: Although an unknown proportion of dacryolithiasis cases may remain asymptomatic; epiphora, acute and/or recurrent dacryocystitis, punctal discharge, and localized swelling are the most common presenting features of dacryolithiasis. It may also present as partial nasolacrimal duct obstruction. Dacryoliths exhibit a variety in external appearances. While some minimally invasive techniques for the removal of dacryoliths have been described, dacryocystorhinostomy with removal of the dacryoliths remain the most effective treatment in cases of symptomatic dacryolithiasis. The expression and production of certain proteins and peptides, namely those of the trifoil factor family play a significant role in the pathogenesis of dacryoliths. CONCLUSIONS: The management of dacryolithiasis is driven by the goal of resolution of secondary obstruction and/or inflammation. Although a large number of dacryoliths are incidentally found during dacryocystorhinostomy, certain clinical features such as unilateral sac distension, particularly those with a palpable firm medial canthal mass, might lead one to have a high index of suspicion. It remains unclear if the incidental finding of a dacryolith during a dacryocystorhinostomy has a favorable prognostic value.

Extramedullary plasmacytoma of the lateral rectus muscle.

Plasmacytoma is an uncommon presentation of plasma cell malignancy, especially in the absence of multiple myeloma. Orbital plasmacytomas generally originate from bone, although few cases in the literature report orbital extramedullary plasmacytomas. We present the case of a 68-year-old man found to have a solitary extramedullary plasmacytoma in the lateral rectus muscle without further evidence of multiple myeloma. This case demonstrates a rare presentation for such a malignancy, and a review of the literature highlights the importance of proper workup and close monitoring to rule out multiple myeloma to guide management.

Trends of Ophthalmic Surgery Cancellations at a County Hospital Before and During COVID-19: A 10-Year Retrospective Study.

PURPOSE: Despite several publications on ophthalmic surgical cancellations discussing preventative causes in academic institutions, there remains a paucity of similar studies for safety-net hospitals. This study analyzed cancellation rates at a county hospital over a 10-year period. METHODS: This retrospective, open cohort study investigated a total of 11,350 surgeries scheduled at a tertiary-level county hospital between January 1, 2012 and December 31, 2021. Surgical cancellation reasons were collected from chart review and categorized into eight groups to allow for analyses. Cancellation rates were then calculated per year and per subspecialty. The primary statistical analyses were paired, 2-tailed t test and χ2 test. RESULTS: The most common reason for cancellation overall was institution-related (1065 surgeries), which was also the most common reason per year from 2012 to 2019 (range: 37.4% - 60.6%). In 2020, during COVID-19 stay-at-home mandates, the most common reason became COVID-related rescheduling, and in 2021, it was patient-driven. The cancellation rate in 2020 was significantly higher than 2019 (+9.27%,95% CI:4.96%-13.6%,p = .05), and significantly lower from 2021 to 2020 (-22.8%,95% CI:-26.8%-(-)18.7%,p = .001). Pediatric surgery had the highest cancellation rate overall (36.4%), but oculoplastics had the highest cancellation rate in 2020 (48.9%). CONCLUSION: The most common reason for cancellation over the 10-year period was institution-related, in contrast to other publications based in academic centers. The study also had a higher cancellation rate than previously reported, again suggesting the difference between county and academic centers. The COVID-19 pandemic had a significant impact on cancellations, even after the COVID-19 stay-at-home orders were eased.

Impact of GLP-1 Agonists and SGLT-2 Inhibitors on Diabetic Retinopathy Progression: An Aggregated Electronic Health Record Data Study.

PURPOSE: To examine the effects of glucagon-like peptide-1 receptor (GLP-1) agonists compared to SGLT-2 inhibitors on diabetic retinopathy. DESIGN: Retrospective clinical cohort study using TriNetX, a federated electronic health records network comprising multiple healthcare organizations. METHODS: Patients with an International Classification of Diseases, Tenth Revision (ICD-10) code of nonproliferative diabetic retinopathy (PDR) and monotherapy treatment, excluding insulin, with GLP-1 agonists or SGLT-2 inhibitors. Patients with a history of PDR prior to initiation of treatment were excluded. The rate of progression to PDR and rate of development of diabetic macular edema (DME) were compared between patients on GLP-1 agonists compared to those on SGLT-2 inhibitors. The groups were propensity score matched for age, gender, ethnicity, race, type of diabetes, and severity of PDR. Main outcomes included rate and relative risk (RR) of progression to PDR and risk of DME in the GLP-1 agonist group versus the SGLT-2 inhibitor group. RESULTS: A total of 6481 patients were identified in the GLP-1 cohort and the SGLT-2 inhibitor cohort after propensity score matching. At 1 and 3 years after initiation of therapy, a higher rate of progression of PDR was noted (RR: 1.26, CI 1.04-1.51, P = .017 at 1 year, RR: 1.284, CI 1.1-1.499, P = .002 at 3 years) in the GLP-1 agonist cohort compared to the SGLT-2 inhibitor cohort. There was a higher rate of DME noted at 3 months (RR: 1.192, CI 1.059-1.276, P = .002), 6 months (RR: 1.22, CI 1.13-1.32, P < .001), 1 year (RR: 1.24, CI 1.15-1.33, P < .001), and at 3 years (RR: 1.29, CI 1.21-1.38, P < .001) in the GLP-1 agonist cohort compared to the SGLT-2 inhibitor cohort. CONCLUSIONS: A higher rate of progression of PDR and risk of new-onset DME was observed in patients on monotherapy with GLP-1 agonists compared to those on SGLT-2 inhibitors. It is important for clinicians to be aware of these potential effects and to consider the current retinopathy status when initiating treatment with newer hypoglycemic agents to ensure these patients are appropriately monitored for developing potential vision-threatening complications.

SYPHILITIC OUTER RETINOPATHY: A MASQUERADING DIAGNOSIS REVEALED AFTER STEROID-INDUCED PROGRESSION TO PANUVEITIS.

PURPOSE: To report a case of syphilitic outer retinopathy revealed after progression to panuveitis after a course of oral steroids for suspected poison ivy. METHODS: Retrospective case report. RESULTS: A 44-year-old diabetic man presented with progressive symptoms of nyctalopia and color vision changes associated with outer retinal disruption on macular imaging but minimal evidence of intraocular inflammation on examination. A short course of oral steroids for an unrelated skin condition induced rapid progression to frank panuveitis with retinal vascular sheathing and retinal whitening. Systemic workup identified syphilis as the etiology. The patient's visual symptoms and disruption of the photoreceptor and retinal pigment epithelial layers on OCT improved after treatment with IV penicillin. CONCLUSION: Syphilitic outer retinopathy represents an unusual manifestation of ocular syphilis that can present with minimal examination findings. We present here a case of oral steroid use resulting in the progression of syphilitic outer retinopathy to a more fulminant form of syphilitic uveitis that ultimately revealed the correct diagnosis and prompted the correct intervention. This case highlights the importance of maintaining a high level of suspicion for this treatable condition.

Simultaneous Bilateral Open-Globe Repair and Vitreoretinal Surgery for Explosive-Related Ocular Injury.

Purpose: To report an approach to explosive injuries with simultaneous, co-surgeon bilateral ruptured globe repair and pars plana vitrectomy for bilateral intraocular foreign bodies (IOFBs). Methods: A case and its findings were analyzed. Results: A 31-year-old man had bilateral vision loss after an air compressor malfunction that caused a high-pressure explosion to his face. An examination showed bilateral open-globe injuries and IOFBs, necessitating urgent repair. Given the risk for endophthalmitis and the need for expeditious repair, open-globe repair surgery was performed in both eyes simultaneously by co-surgeons followed by pars plana lensectomy, vitrectomy with IOFB removal, and silicone oil placement. The final visual acuity after bilateral scleral-fixated intraocular lens implantation was 20/20 OD and 20/25 OS. Conclusions: This case of bilateral open-globe injuries and IOFBs required expeditious repair with bilateral, simultaneous surgery that ultimately resulted in excellent visual outcomes. Simultaneous surgery may be an option for bilateral ocular trauma.

Intraoperative Complications With Vitreous Biopsy for Molecular Proteomics.

OBJECTIVE: To study the incidence of intraoperative complications while collecting a vitreous sample for proteomic biomarker analyses during small-gauge pars plana vitrectomy (PPV). METHODS: A retrospective case series was assembled from the surgical logs and charts of patients who underwent 23-, 25-, and 27-gauge PPV along with an undiluted vitreous biopsy. Primary surgical indication and detailed operative reports were reviewed. Complications specific to vitreous biopsy were assessed while complications related to vitrectomy in general without biopsy were not tabulated. RESULTS: In 1190 eyes that underwent vitreous biopsy, the most common indications for PPV were rhegmatogenous retinal detachment (24.2%), epiretinal membrane (ERM) (21.7%), vitreous hemorrhage (11.0%), uveitis (8.3%), and macular hole (7.5%). An adequate sample of 0.5 cc to 1.0 cc was obtained in all cases. There was one sclerotomy break associated with biopsy, but no instances of lens touch, retinal contusion, retinal detachment, or intraocular hemorrhage. CONCLUSIONS: Undiluted vitreous biopsy obtained at the time of small-gauge vitrectomy is a generally safe procedure and may be considered for collection of samples for proteomic analysis. [Ophthalmic Surg Lasers Imaging Retina 2023;54:32-36.].

AI-Human Hybrid Workflow Enhances Teleophthalmology for the Detection of Diabetic Retinopathy.

Objective: Detection of diabetic retinopathy (DR) outside of specialized eye care settings is an important means of access to vision-preserving health maintenance. Remote interpretation of fundus photographs acquired in a primary care or other nonophthalmic setting in a store-and-forward manner is a predominant paradigm of teleophthalmology screening programs. Artificial intelligence (AI)-based image interpretation offers an alternative means of DR detection. IDx-DR (Digital Diagnostics Inc) is a Food and Drug Administration-authorized autonomous testing device for DR. We evaluated the diagnostic performance of IDx-DR compared with human-based teleophthalmology over 2 and a half years. Additionally, we evaluated an AI-human hybrid workflow that combines AI-system evaluation with human expert-based assessment for referable cases. Design: Prospective cohort study and retrospective analysis. Participants: Diabetic patients ≥ 18 years old without a prior DR diagnosis or DR examination in the past year presenting for routine DR screening in a primary care clinic. Methods: Macula-centered and optic nerve-centered fundus photographs were evaluated by an AI algorithm followed by consensus-based overreading by retina specialists at the Stanford Ophthalmic Reading Center. Detection of more-than-mild diabetic retinopathy (MTMDR) was compared with in-person examination by a retina specialist. Main Outcome Measures: Sensitivity, specificity, accuracy, positive predictive value, and gradability achieved by the AI algorithm and retina specialists. Results: The AI algorithm had higher sensitivity (95.5% sensitivity; 95% confidence interval [CI], 86.7%-100%) but lower specificity (60.3% specificity; 95% CI, 47.7%-72.9%) for detection of MTMDR compared with remote image interpretation by retina specialists (69.5% sensitivity; 95% CI, 50.7%-88.3%; 96.9% specificity; 95% CI, 93.5%-100%). Gradability of encounters was also lower for the AI algorithm (62.5%) compared with retina specialists (93.1%). A 2-step AI-human hybrid workflow in which the AI algorithm initially rendered an assessment followed by overread by a retina specialist of MTMDR-positive encounters resulted in a sensitivity of 95.5% (95% CI, 86.7%-100%) and a specificity of 98.2% (95% CI, 94.6%-100%). Similarly, a 2-step overread by retina specialists of AI-ungradable encounters improved gradability from 63.5% to 95.6% of encounters. Conclusions: Implementation of an AI-human hybrid teleophthalmology workflow may both decrease reliance on human specialist effort and improve diagnostic accuracy. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.

Surgical management of acanthamoeba chorioretinitis.

PURPOSE: Acanthamoeba chorioretinitis is a rare manifestation of the parasitic infection, and reported cases often result in enucleation. Surgical removal of Acanthamoeba chorioretinitis has not been previously described. We report a surgical case of Acanthamoeba chorioretinitis spread from keratitis that ultimately resulted in a disease-free outcome. OBSERVATIONS: A healthy 80-year-old male with a history of keratoconus requiring a penetrating keratoplasty in the fellow eye presented with a severe corneal ulcer clinically consistent with Acanthamoeba keratitis. He ultimately required a penetrating keratoplasty and improved clinically until he developed vitritis on post-operative month 1 and was diagnosed with endophthalmitis. B-scan ultrasound demonstrated vitreous opacities and a large retinal mass that reduced in size following serial intravitreal injections of antibiotics, oral antibiotics, and a limited pars plana vitrectomy. He underwent a repeat pars plana vitrectomy 6 weeks later and a retinal mass in the mid-periphery with an associated tractional retinal detachment was noted. A localized retinectomy was performed around the lesion which was excised entirely, and silicone oil was instilled. Pathology of the lesion showed acute and chronic granulomatous necrotizing inflammation with the presence of several definitive amoebic organisms and numerous cells suspicious for amoebae. The patient was maintained on oral antibiotics by the Infectious Disease Service and was disease-free 1-year post-infection. CONCLUSIONS AND IMPORTANCE: Acanthamoeba chorioretinitis is a rare, devastating disease and often leads to enucleation. We present a surgical case showing control of the infection utilizing a surgical retinectomy. Aggressive local therapy and a multidisciplinary approach with the Infectious Disease Service may lead to a successful outcome.

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.

Intravitreal brolucizumab as treatment of early onset radiation retinopathy secondary to plaque brachytherapy for choroidal melanoma.

Purpose: To describe the efficacy and safety of brolucizumab (Beovu®, Novartis Pharmaceuticals) in a case of cystoid macular edema associated with radiation retinopathy as a result of iodine-125 plaque brachytherapy (PBT) for choroidal melanoma, resistant to treatment with other anti-vascular endothelial growth factor (VEGF) agents. Observations: A 67-year-old woman with choroidal melanoma in the right eye and best-corrected visual acuity (BCVA) of 20/20, underwent uncomplicated PBT. On post-operative month 7, the patient developed early onset radiation retinopathy. She failed to improve significantly with sub-tenon triamcinolone and 3 injections of intravitreal bevacizumab; BCVA was 20/200. Intravitreal brolucizumab was administered, and one month after, macular edema had resolved completely on optical coherence tomography, and BCVA improved to 20/50. At last follow up, 1 month after the third brolucizumab injection, BCVA was 20/60 and there was sustained resolution of intraretinal fluid. There were no signs of intraocular inflammation, progressive RR or optic neuropathy on exam or fluorescein angiography. Conclusions: This case suggests a positive effect of brolucizumab in the management of radiation retinopathy following PBT refractory to other anti-VEGF agents. However, one must consider the risk of severe vision loss associated with retinal vasculitis from use of brolucizumab.

Wide-Field Swept-Source Optical Coherence Tomography of Optic Disc Pit Maculopathy Demonstrates Connection Between Vitreous and Subretinal Fluid.

The source of subretinal or intraretinal fluid in patients with optic disc pit maculopathy (ODP-M) remains unclear and is often thought to be either vitreous or cerebrospinal fluid.1 Here, we present the case of a 40-year-old man who developed ODP-M. Further imaging with wide-field swept-source optical coherence tomography demonstrated that the macular fluid was tracking from a nasal optic disc pit with superonasal communication to the vitreous. This suggests that swept-source optical coherence tomography can be a useful tool for determining the origin of macular fluid in patients with ODP-M. [Ophthalmic Surg Lasers Imaging Retina 2022;53:579-581.].

Impact of Early COVID-19 Pandemic on Common Ophthalmic Procedures Volumes: A US Claims-Based Analysis.

PURPOSE: The COVID-19 pandemic has had a profound effect on the delivery of healthcare in the United States and globally. The aim of this study was to evaluate the impact of COVID-19 on common ophthalmic procedure utilization and normalization to pre-pandemic daily rates. METHODS: Leveraging a national database, Clinformatics™ DataMart (OptumInsight, Eden Prairie, MN), procedure frequencies and daily averages, defined by Current Procedural Terminology codes, of common elective and non-elective procedures within multiple ophthalmology sub-specialties were calculated. Interrupted time-series analysis with a Poisson regression model and smooth spline functions was used to model trends in pre-COVID-19 (January 1, 2018-February 29, 2020) and COVID-19 (March 1, 2020-June 30, 2020) periods. RESULTS: Of 3,583,231 procedures in the study period, 339,607 occurred during the early COVID-19 time period. Anti-vascular endothelial growth factor injections (44,412 to 39,774, RR 1.01, CI 0.99-1.02; p = .212), retinal detachment repairs (1,290 to 1,086, RR 1.07, CI 0.99-1.15; p = .103), and glaucoma drainage implants/trabeculectomies (706 to 487, RR 0.93, CI 0.83-1.04; p = .200) remained stable. Cataract surgery (61,421 to 33,054, RR 0.77; CI 0.76-0.78; p < .001), laser peripheral iridotomy (1,875 to 890, RR 0.82, CI 0.76-0.88; p < .001), laser trabeculoplasty (2,680 to 1,753, RR 0.79, CI 0.74-0.84; p < .001), and blepharoplasty (1,522 to 797, RR 0.71, CI 0.66-0.77; p < .001) all declined significantly. All procedures except laser iridotomy returned to pre-COVID19 rates by June 2020. CONCLUSION: Most ophthalmic procedures that significantly declined during the COVID-19 pandemic were elective procedures. Among these, the majority returned to 2019 daily averages by June 2020.

Applicant Characteristics Associated with Retina Fellowship Match from 2010-2019.

OBJECTIVE: To describe trends in the surgical and medical retina fellowship match and applicant characteristics associated with matching in retina fellowship. DESIGN: Retrospective study. SUBJECTS: Ophthalmology fellowship applicants who applied through the San Francisco (SF) Match. METHODS: Publicly available SF Match data were used to describe trends in the number of programs participating and positions offered, filled, and left vacant in the retina fellowship match from 2014 to 2019. Deidentified applicant data for match cycles from 2010 to 2017 were stratified by match status, and characteristics were compared across groups. Trends in matched applicant characteristics were evaluated using linear regression on log-transformed variables. Multivariable logistic regression was used to determine applicant characteristics that were associated with a successful match. MAIN OUTCOME MEASURES: Match status. RESULTS: From 2014 to 2019, the number of programs participating, positions filled, and positions left vacant in the retina fellowship match increased from 101 to 119 (P = 0.010), 118 to 123 (P = 0.078), and 18 to 37 (P = 0.045), respectively. Compared with unmatched applicants, matched applicants were more likely to have graduated from a top 10 residency program, US residency, or medical school; hold a United States (US) visa (J-1, H-1B, or O1); distribute more applications; complete more interviews; rank more programs; and score higher on the United States Medical Licensing Examination (USMLE) Step examinations 1-3. Matched applicants completed a median of 10 interviews. After controlling for potential covariates, graduating from a US residency (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.48-2.92), a top 10 residency (OR, 1.74; 95% CI, 1.07-2.84), having an allopathic medical degree (MD; OR, 2.39; 95% CI, 1.08-5.33), completing more interviews (OR, 1.28; 95% CI, 1.23-1.33), and scoring higher on USMLE Step 3 (OR, 1.01; 95% CI, 1.01-1.03) were associated with matching into a retina fellowship. CONCLUSIONS: Although the number of programs participating and positions offered in the retina fellowship match are increasing, the number of positions filled remained relatively stagnant. Factors associated with matching in both medical and surgical retina included graduating from a US and top 10-ranked residency program, having an MD, completing more interviews, and scoring higher on USMLE Step 3.

CRB1-associated retinal dystrophy presenting as self-resolving opsoclonus and posterior uveitis.

PURPOSE: To describe the unusual case of inflammatory CRB1-associated retinal dystrophy that initially presented with self-resolving opsoclonus. OBSERVATIONS: We report the case of a now 2-year-old female who developed opsoclonus without myoclonus at the age of 4 months. An extensive workup for neuroblastoma and other systemic diseases was unremarkable, and all unusual eye movements self-resolved at age 10 months. Twenty-one months after initial presentation, she began having reduced visual behaviors, and comprehensive ophthalmic exam at that time revealed recurrent saccadic intrusions as well as severe, chronic retinal inflammation and dystrophic changes. An extensive infectious and inflammatory workup was negative. Genetic sequencing revealed two variants in CRB1: a heterozygous missense mutation and a heterozygous novel deletion involving exon 12. The patient was treated with monthly infliximab and methylprednisolone infusions with improvement in her optic disc and macular capillary leakage. The patient's 8-month-old sister also harbored the same variants in CRB1 and had early signs of retinal dystrophy and peripheral vascular leakage on exam. CONCLUSION: Saccadic intrusions may be the first sign of a retinal dystrophy, and infants and children with this presentation should undergo a complete eye exam. We further highlight the link between CRB1-associated retinal dystrophy and inflammation, and how systemic steroids and tumor necrosis factor alpha (TNF-α) inhibitors may be effective therapies. Finally, we report a novel deletion in CRB1 that is likely highly penetrant.

Immunotherapy-induced retinopathy mimicking cancer associated retinopathy.

Purpose: To report a patient who developed a cancer associated retinopathy (CAR) like syndrome in the setting of pembrolizumab and lenvatinib combination therapy for metastatic endometrial carcinoma. Symptoms resolved with normalization of objective functional tests following cessation of medications. Observations: A 52-year-old female with history of endometrial carcinoma, managed with pembrolizumab infusions and daily oral lenvatinib treatment for 18 months, presented to a tertiary eye center with complaints of nyctalopia, photosensitivity and photopsia. Further investigations revealed a reduction in b-wave amplitude on full field ERG (ffERG), a mild color vision deficit, and positive antiretinal antibodies against carbonic anhydrase II, enolase and arrestin. A preliminary diagnosis of CAR was made. One month following diagnosis, the patient discontinued both lenvatinib and pembrolizumab and subsequently reported significant improvement in her eye symptoms and vision. Repeat ffERG had normalized with a robust b-wave, with an improvement noted on repeat color vision testing. A presumed diagnosis of immunotherapy-induced retinopathy was made, with clinical findings mimicking CAR. Conclusions and importance: Pembrolizumab and lenvatinib treatment may be associated with a reversible retinopathy, with presentation very similar to CAR.