Sexually transmitted infections and HIV in ophthalmology.

The ocular and periocular manifestations of sexually transmitted infections are heterogeneous in etiology, manifestations, and complications. Etiologic agents include bacteria, viruses, parasites, and protozoa, which are most frequently transmitted via direct ocular contact with an active lesion or infected bodily fluid, autoinoculation, or dissemination from a distant site. Vertical transmission most commonly occurs perinatally during vaginal delivery. The complications of ophthalmia neonatorum can be severe, with the potential for permanent blindness or life-threatening systemic involvement if untreated. Clinical features, diagnostic modalities, and therapeutic regimens vary based on etiology and are summarized in this review. Prompt diagnosis is imperative, given the severe sequelae that may result from ocular involvement in these infections, including permanent vision loss. A multidisciplinary approach, involving both ophthalmology and dermatology, to diagnosis and management is essential to mitigate the risk of morbidity associated with sexually transmitted infections resulting in eye disease.

Sexually Transmitted Infections and HIV in Ophthalmology.

The ocular and periocular manifestations of sexually transmitted infections (STIs) are heterogeneous in etiology, manifestations, and complications. Etiologic agents include bacteria, viruses, parasites, and protozoa, which are most frequently transmitted via direct ocular contact with an active lesion or infected bodily fluid, autoinoculation, or dissemination from a distant site. Vertical transmission most commonly occurs perinatally during vaginal delivery. The complications of ophthalmia neonatorum can be severe with the potential for permanent blindness or life-threatening systemic involvement if untreated. Clinical features, diagnostic modalities, and therapeutic regimens vary based on etiology and are summarized in this review. Prompt diagnosis is imperative, given the severe sequelae that may result from ocular involvement in these infections, including permanent vision loss. A multidisciplinary approach, involving both ophthalmology and dermatology, to diagnosis and management is essential to mitigate the risk of morbidity associated with STIs resulting in eye disease.

Unusual presentation of CREST retinal vasculitis.

PURPOSE: To report a case of CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias) syndrome-induced retinal vasculitis in the setting of ocular inflammation soon after recent micropulse cyclophotocoagulation (mTS-CPC). OBSERVATIONS: Our patient developed CREST associated retinal vasculitis in both eyes (right > left) eight days after receiving mTS-CPC in her left eye. There was initial concern for sympathetic ophthalmia due to the resulting bilateral inflammation. The patient was treated with prednisone with resolution of her symptoms. CONCLUSIONS: This is the first case of CREST retinal vasculitis that appears to be directly triggered by inflammation caused by mTS-CPC.

A SERIES OF FIVE PATIENTS WITH FOVEAL HYPOPLASIA DEMONSTRATING GOOD VISUAL ACUITY.

BACKGROUND/PURPOSE: Foveal hypoplasia is associated with low vision in a variety of conditions. We report and show imaging studies for a series of five patients with foveal hypoplasia who had visual acuity ranging from 20/25 to 20/60. METHODS: Observational case series. PATIENTS: This series includes five patients aged 5 to 18 years who presented to the Greater Baltimore Medical Center, Hoover Low Vision Clinic. All patients showed a partial or complete absence of the fovea in both eyes on examination. RESULTS: Eight eyes exhibited absence of foveal depression on spectral domain optical coherence tomography (Cirrus high-definition OCT; Carl Zeiss Meditec). Four eyes exhibited Grade 3 foveal hypoplasia, two eyes exhibited Grade 4 foveal hypoplasia, and two eyes exhibited Grade 1 foveal hypoplasia. For two eyes (one patient), the optical coherence tomography was no longer available for grading, but was interpreted as foveal hypoplasia in both eyes in the chart. Visual acuities ranged from 20/25 to 20/60. Only two of five patients showed signs of albinism. CONCLUSION: Despite the presence of foveal hypoplasia, patients can retain a high level of visual acuity, which suggests that a foveal depression is not essential for the development of good visual acuity.

Combined Endocyclophotocoagulation and Phacoemulsification in Patients with Glaucoma of African Descent.

The aim of this study was to evaluate the outcomes of combined endocyclophotocoagulation (ECP) and phacoemulsification regarding vision, refraction, intraocular pressure (IOP), medication dependence, and complications in patients of African descent. A retrospective chart review was performed including all cases of ECP combined with phacoemulsification from October 2015 to March 2017. Exclusion criteria consisted of patients who were not of African descent and patients with <1 month follow-up. IOP was the primary outcome. Thirty-two eyes of 29 patients were included in the study. Mean ± standard deviation (SD) of IOP decreased from 17.30 ± 6.30 mmHg preoperatively to 15.88 ± 4.23 mmHg at the last postoperative visit (P = 0.301). In 2 of eight patients who did not demonstrate a difference in pre- and postoperative IOP changes, all IOP lowering medications were stopped. The mean ± SD of follow-up was 5.05 ± 4.08 months with a range of 1 to 18 months. The mean ± SD number of medications used for each patient for IOP control decreased from 2.59 ± 1.01 preoperatively to 1.97 ±1.38 (P = 0.045). Average visual acuity improved from 20/50 preoperatively to 20/25 (P = 0.002). Postoperative complication rate was low. ECP combined with phacoemulsification was effective to decrease IOP lowering medication dependence in patients of African descent. We found that combined ECP and phacoemulsification can lead to a significantly decreased dependence on IOP lowering drops, with some patients demonstrating complete independence from drops following surgery. Although there was not a significant decrease in IOP postoperatively when analyzed collectively, larger studies might to find such an association. Combined ECP and phacoemulsification has been shown to be a safe combination in patients with refractive glaucoma and may be considered if a patient desire less dependence on IOP lowering drops once other first-line methods have failed, or as a bridge between conservative and more definitive surgical treatment.

A practical approach to ocular pain for the non-ophthalmologist.

Pain involving the eye has numerous etiologies and is a feared challenge of many clinicians. Between a fear of the patient losing vision and a lack of familiarity with the ophthalmic equipment necessary to diagnose the problem, working up eye pain can be a daunting task. While the ophthalmologist can be indispensable in challenging cases of eye pain, this article will help clarify the unique clinical features of each etiology that can help clinicians narrow down the differential and arrive at a diagnosis.

Pain of ocular and periocular origin.

Most diseases of the eye and periocular regions that cause blindness are relatively painless. Headache pain of ocular and periocular origin represent a special challenge to the clinician. For patients with ocular and periocular pain that is unrelated to primary eye disease, identification and treatment of the painful condition usually become the responsibility of the clinician.

Headache pain of ear, nose, throat, and sinus origin.

Pain of the ear, nose, sinuses, and throat is commonly encountered in clinical practice. For the most part, the pathologic process responsible for the patient's symptoms is easily identifiable after the physician performs a targeted history and physical examination. Unfortunately, the nature of this anatomic region makes it possible for the most thorough physician to miss pathologic factors that may ultimately harm the patient. For this reason, the following rules for the treatment of ear, nose, sinus, and throat pain serve both the patient and the clinician well: (1) take a targeted history; (2) perform a careful, targeted physical examination; (3) heed the warning signs of serious disease, such as fever, constitutional symptoms, or weight loss; (4) image early and frequently if the diagnosis remains elusive; (5) perform laboratory tests that help identify "sick from well," such as erythrocyte sedimentation rate, hematology, and blood tests; (6) avoid attributing the patient's pain to idiopathic or psychogenic causes; and (7) always assume that you have missed the diagnosis.

Giant cell arteritis.

GCA is the prime medical emergency in ophthalmology because it may result in loss of vision in 1 or both eyes. This vision loss is preventable if patients are diagnosed early and treated immediately with high doses of corticosteroids.

Comparing the efficacy of the monocular trial treatment paradigm with multiple measurements of intraocular pressure before and after treatment initiation in primary open-angle glaucoma.

The monocular trial has been proposed as a test to help control for diurnal fluctuations in eye pressure when assessing medication effectiveness. We undertook a prospective study to determine the sensitivity and specificity of the monocular trial as a test for determining the effectiveness of a glaucoma medication. The efficacy of the monocular trial was compared to the diagnostic paradigm of repeated pre- and post-treatment measurements in determining whether an intraocular pressure (IOP)-lowering drug is effective. Forty-two patients with newly diagnosed open-angle glaucoma completed five visits: visit 1 for determining eligibility, obtaining consent, and measuring IOP, visit 2 for a second pressure measurement, and visit 3 for a third pressure reading. The new medication was then started in one eye. IOP measurements were made at weeks 4 and 6. The gold standard IOP change was defined as the difference in mean between the pre- and post-medication visits. A medication was deemed effective if this difference was at least 15%. The monocular trial pressure change was defined as the IOP change in the treated eye between the visit immediately before and immediately after the medication addition, corrected by subtracting the pressure change in the untreated eye. All 42 patients completed the full protocol with good compliance. Twenty-five of 42 (60%) medication additions were considered effective by the gold standard method, and 25/42 (60%) by the monocular trial method. However, the two methods agreed in only 26 patients (17 Yes/Yes, 9 No/No). The calculated sensitivity was low (0.68), with a specificity of 0.53. The monocular trial can give useful clues as to whether a medication is effective, but should not be the only information used in making this determination. To obtain the most valid results, multiple pressure checks should be done before and after starting a new medication.