Non-organic Vision Loss in the Afghanistan and Iraq Conflicts.

Non-organic visual loss (NOVL), defined as a decrease in visual acuity or field without an identifiable organic cause, can be challenging to diagnose, especially in patients whose NOVL is superimposed on some component of true organic pathology. Exposure to combat puts soldiers at risk of emotional distress and physical trauma, which can contribute to the development of NOVL with conversion disorder or malingering. This case series describes six patients with NOVL who sustained ocular or non-ocular injuries while serving in combat operations in Iraq and Afghanistan, and highlights diagnostic pearls and components of inter-disciplinary management in the unique military context.

Sociodemographic and Clinical Predictors of Prolonged Length of Corneal Ulcer Hospitalizations.

Importance: The length of stay (LOS) of hospitalizations may be a useful indicator of the burden of disease of corneal ulcers. Identifying variables associated with longer LOS may help to enhance delivery of care for high-risk patients. Objective: To investigate the sociodemographic, social, and clinical factors associated with LOS in hospitalizations for corneal ulcers in the US. Design, Setting, and Participants: This was a retrospective cross-sectional study of adult patients (aged >18 years) admitted with a primary diagnosis of corneal ulcer between quarter 4 of 2015 through 2020 and conducted using data from the National Inpatient Sample (NIS). Patients were stratified into 2 even cohorts based on LOS: LOS of 4 days or less and LOS greater than 4 days. Individual-level sociodemographic, social risk factors, and medical comorbidities associated with longer LOS were examined by multivariable regression. Data were analyzed from October 2015 to December 2020. Exposure: Potential sociodemographics or medical comorbidities at hospital admission. Main Outcome and Measure: The primary outcome of interest was factors associated with extended length of stay. The hypothesis being tested was formulated during data collection. Results: A total of 1187 patients (mean [SD] age, 53.5 [20.9] years; 602 female [50.7%]) were included for analysis. The cohort with LOS greater than 4 days had higher total charges than the cohort with LOS of 4 days or less (mean [SD] charges, $79 504 [$86 719] vs $26 474 [$20 743]; P < .001). Sociodemographic variables associated with LOS greater than 4 days were Black race (adjusted odds ratio [aOR], 1.41; 95% CI, 1.03-1.92; P = .03), Medicare insurance (aOR, 1.42; 95% CI, 1.09-1.85; P = .009), and housing insecurity (aOR, 1.99; 95% CI, 1.29-3.06; P = .002). Medical comorbidities associated with LOS greater than 4 days were alcohol use (aOR, 1.50; 95% CI, 1.00-2.26; P = .05), dementia (aOR, 2.35; 95% CI, 1.36-4.07; P = .002), complicated diabetes (aOR, 1.75; 95% CI, 1.21-2.53; P = .003), uncomplicated diabetes (aOR, 1.57; 95% CI, 1.02-2.42; P = .04), drug misuse (aOR, 1.66; 95% CI, 1.08-2.57; P = .02), and legal blindness (aOR, 3.42; 95% CI, 1.19-9.82; P = .02). Based on NIS national estimates, corneal ulcers were estimated to have a direct annual health care expenditure of $35 819 590 in the US. Conclusion and Relevance: Corneal ulcer hospitalizations represent a significant burden of disease for patients and health care systems. This study highlights sociodemographic and clinical factors that may help clinicians identify high-risk patients vulnerable to complications and morbidity due to corneal ulcers.

Update on ocular tuberculosis.

PURPOSE OF REVIEW: Despite recent downtrends, tuberculosis remains a worldwide public health concern. This review provides an update on recent demographic data, clinical and experimental data, and diagnostic modalities. RECENT FINDINGS: Quantitative PCR showing mycobacterial load in intraocular fluids may have an emerging role in the diagnosis of ocular tuberculosis when used in combination with ophthalmic features of tuberculosis. Recent investigations in porcine models of ocular tuberculosis have provided valuable insight into the microbiologic, histologic, and clinical features of Mycobacterium tuberculosis infection of the choroid. Differentiating features between sarcoidosis and tuberculosis include tuberculin skin test status, the presence of ocular surface disease, and the anatomic relationship between vasculitis and choroiditis. SUMMARY: The diagnosis of presumed ocular tuberculosis remains a clinical challenge with currently available diagnostic modalities. Although newer interferon-γ release assays can distinguish exposure to M. tuberculosis from the Bacille-Calmette-Guérin vaccine strain, they currently lack the specificity to distinguish between latent tuberculosis infection and active tuberculosis. Continued improvement in the currently available molecular diagnostic techniques including quantitative PCR may be valuable in our ability to establish an earlier etiologic diagnosis and institute appropriate antimycobacterial therapy.

Alcohol versus brush PRK: visual outcomes and adverse effects.

BACKGROUND AND OBJECTIVE: A smooth corneal surface prior to laser ablation is important in order to achieve a favorable refractive outcome. In this study, we compare PRK outcomes following two commonly used methods of epithelial debridement: Amoils epithelial scrubber (brush) versus 20% ethanol (alcohol). STUDY DESIGN/PATIENTS AND METHODS: We reviewed records of patients who underwent wavefront-optimized PRK for myopia or myopic astigmatism between January 2008 and June 2010. Two treatment groups (brush vs. alcohol) were compared in terms of uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent (MRSE), corrected distance visual acuity (CDVA), and complications at postoperative months 1, 3, 6, and 12. RESULTS: One thousand five hundred ninety-three eyes of 804 patients underwent PRK during the study period: 828 brush-treated eyes and 765 alcohol-treated eyes. At 6 months postoperatively UDVA was ≥20/20 in 94.7% of brush-treated eyes versus 94.4% of alcohol-treated eyes (P = 0.907). At 1 month a higher percentage of brush-treated eyes maintained or gained one or more lines CDVA compared to alcohol-treated eyes (P = 0.007), but there were no other differences in UDVA, MRSE, or CDVA at any point postoperatively. At 1 month 75.4% of brush-treated eyes versus 70.4% of alcohol-treated eyes were free of complications (P = 0.032), and there were fewer brush-treated eyes with corneal haze (4.0% vs. 6.9%, P = 0.012) and dry eye (8.9% vs. 14.4%, P = 0.001). Although corneal haze was slightly more frequent in the alcohol group, most was trace and not significant. CONCLUSIONS: Although alcohol-assisted PRK had more minor complications in the early postoperative period, including corneal haze and dry eye, results for both groups beyond 1 month were comparable.

Ocular tuberculosis: a clinicopathologic and molecular study.

OBJECTIVE: To analyze the clinical profiles, histopathologic features, and Mycobacterium tuberculosis polymerase chain reaction testing in patients with ocular tuberculosis. DESIGN: Retrospective case series. PARTICIPANTS: Forty-two patients. METHODS: This retrospective study was approved by the Armed Forces Institute of Pathology (AFIP) Institutional Review Board. The AFIP data banks were screened for cases with diagnosis of ocular tuberculosis using key words such as mycobacterium; tuberculosis; and acid-fast bacilli. Files and slides stained with hematoxylin-eosin and acid-fast staining were reviewed by the Division of Ocular Pathology and by the Infectious Diseases and Parasitic Diseases Pathology Branches. When available; blocks and unstained slides were sent to the Doheny Eye Institute; Los Angeles; California; for quantitative polymerase chain reaction (qPCR) analysis to detect Mycobacterium tuberculosis-specific DNA. MAIN OUTCOME MEASURES: Tuberculin skin test (TST) results, as well as the chest radiograph results, were recorded. When acid-fast bacilli were identified in tissue, their locations-ocular or extraocular sites-were recorded. Emphasis was placed on lymph node involvement and any systemic diseases. RESULTS: In the histopathologic specimens, microscopy revealed a paucity of organisms, and often there were only 1 or 2 organisms associated with or near a giant cell or near an area of necrosis. The qPCR analysis was performed on 6 biopsy specimens. These specimens showed necrotizing granulomatous inflammation from 6 different patients; 3 had positive qPCR results. In 2 of the 3 cases with positive qPCR results, acid-fast bacilli were not found in the tissue sections. In 17 patients, TST results were available; 10 had positive results (60%) and 7 had negative results (40%). Fourteen chest radiograph results were submitted, and 8 (57%) of 14 patients had normal chest films. CONCLUSIONS: This study suggests that in dealing with those populations at increased risk of tuberculosis (e.g., immigrants from endemic areas and human immunodeficiency virus-infected patients) or patients receiving biologic therapy, the ophthalmologist should endeavor to entertain this diagnosis and to rely on the support of infectious disease specialists and pulmonologists to help solidify the diagnosis, because the current methods for the diagnosis have limited sensitivity.

Visual and IOP outcomes after PRK in pigment dispersion syndrome.

PURPOSE: To report the results of photorefractive keratectomy (PRK) in patients with pigment dispersion syndrome. METHODS: The pre- and postoperative records of patients with pigment dispersion syndrome who underwent PRK between January 2002 and March 2009 were reviewed. Data for analysis included gender, age, ablation depth, surgical complications, manifest refraction spherical equivalent, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), intraocular pressure (IOP), central corneal thickness (CCT), cup-to-disc (c/d) ratio, and postoperative complications. RESULTS: Thirty-seven eyes of 19 patients (17 men and 2 women) with a mean age of 37.5 ± 6.9 years were included for review. At final follow-up, mean 404.1±119.5 days postoperative, UDVA was 20/15 or better in 67.6%, 20/20 or better in 91.9%, and 20/25 or better in 100% of eyes; 94.6% of eyes were within 0.50 diopters (D) and 100% were within 1.00 D of emmetropia. Corrected distance visual acuity was unchanged from preoperative in 73% and improved by one line in 27% of eyes. No eye lost 1 or more lines of CDVA. When corrected for change in CCT and curvature, mean postoperative IOP was elevated from baseline (16.7 ± 3.8 mmHg) at 1 month (18.1 ± 4.9 mmHg, P =.044) but unchanged at any other time postoperatively. Two (11%) of 19 patients were steroid responders, requiring a single topical agent until completing the course of steroids. No significant change was noted in mean c/d ratio from baseline (0.35±0.12) to final postoperative (0.35 ± 0.13, P = .99). CONCLUSIONS: Although PRK in patients with pigment dispersion syndrome resulted in excellent UDVA, retention of CDVA, and low incidence of adverse effects 1 to 2 years after surgery, long-term safety and efficacy outcomes of PRK in this cohort remain speculative

A randomized pilot study of systemic immunosuppression in the treatment of age-related macular degeneration with choroidal neovascularization.

BACKGROUND: Age-related macular degeneration remains the leading cause of irreversible blindness in the United States and the developed world. Intravitreal injections of anti­vascular endothelial growth factor (VEGF) medications have become standard of care for the treatment of the wet form of the disease. Recent reports have demonstrated an association with various immune factors. We aimed to investigate the effect of immunosuppressive therapy in the clinical course of the wet form of the disease. We compared anti-VEGF therapy plus one of three systemic immunosuppressive therapies versus anti-VEGF therapy alone for recurrent choroidal neovascularization associated with age-related macular degeneration. METHODS: This was a pilot, Phase I/II, prospective, randomized, unmasked, single-center trial. Patients with subretinal exudation secondary to recurrent choroidal neovascularization associated with age-related macular degeneration were included in the study. Patients were randomized to 1 of 3 systemic arms immunosuppressive agents (daclizumab, rapamycin, or infliximab) for 6 months plus intraocular anti-VEGF therapy if indicated, compared with a group who received only anti-VEGF therapy if indicated. RESULTS: The number of anti-VEGF injections per group, visual acuity, retinal thickness, and safety measures were assessed in all groups. Thirteen patients were randomized; comparing anti-VEGF injections before and during the study, a decrease in the number of injections from 0.73 injections per month to 0.42 for daclizumab and from 0.67 to 0.34 for sirolimus was seen, while no apparent decrease was seen for either infliximab or observation. Visual acuities were maintained in all groups. CONCLUSION: These preliminary data suggest that some immunosuppressive agents given systemically can alter the clinical course of the wet form of the disease and support the notion that more definitive clinical trials of immune mediation of age-related macular degeneration are indicated.

The AFIP history of ocular leprosy.

PURPOSE: To investigate the Armed Forces Institute of Pathology (AFIP) experience with Ocular Leprosy. METHODS: The AFIP data banks were screened for cases with diagnosis of ocular leprosy. Files and slides stained with Hematoxylin-eosin and acid-fast staining were reviewed by the Division of Ocular Pathology and by the Infectious Diseases Pathology Branch. RESULTS: Twenty-five cases were found from 1951 to 1985 and there were 15 males and 7 females and in 3 cases the sex was not given. The disease process ran from 4 months to 50 years in this series. Three patients also had systemic mycobacterium tuberculosis infections. The clinical manifestations of leprosy did not correlate with the histopathological findings. Clinically, corneal manifestations were the most common clinical presentation in 15 cases with only one perforation, iridocyclitis following in 9 patients and eyelid abnormalities ranging from ectropion to trichiasis in 7 patients. Two patients at autopsy had lepromatous cells in the ciliary body as the only ocular manifestation. CONCLUSIONS: In summary, this paper represents a series of ocular leprosy cases from the AFIP which shows the severity of ocular involvement, the predilection of anterior segment involvement and a large number of histopathologic indeterminate cases. The current immigrant and refugee crisis warrants revisting this ancient disease in the differential diagnosis.

A review of pediatric uveitis: part II. Autoimmune diseases and treatment modalities.

Uveitis is a manifestation of complex processes that can represent an infectious process or a dysfunction of the immune system that may have grave effects on the eye. Although infectious causes, once properly identified, may be successfully treated by addressing the inciting organism with recognized interventions, the immune-modulated chronic forms of uveitis often provide more complex challenges in management. Recent strides in understanding the inflammatory pathway and better bioengineering capabilities have resulted in some new modalities of treatment.

A review of pediatric uveitis: Part I. Infectious causes and the masquerade syndromes.

Uveitis is a manifestation of complex processes that can represent an infectious or a purely immune system modulated condition and may have grave effects on the eye. Much of the morbidity in these conditions is the result of the immune response to these stimuli. These infectious diseases may be successfully treated by addressing the inciting organism with recognized interventions. Treatment of the immune response to the organism often must be pursued simultaneously to minimize long-term complications caused by structural changes within the eye. Assisting the individual's immune response to eliminate the organism while minimizing the immune response's damaging effects remains a unique challenge drawing on both the science and the art of medicine. Several non-infectious conditions that are not autoimmune diseases may commonly masquerade as uveitis, leading to delays in appropriate treatment.

Subconjunctival Nodule in a Patient With Acute Monkeypox.

This case report describes a patient with acute monkeypox with a subconjunctival nodule.

Infectious keratitis after photorefractive keratectomy in the United States army and navy.

PURPOSE: To review the incidence, culture results, clinical course, management, and visual outcomes of infectious keratitis after photorefractive keratectomy (PRK) at 6 Army and Navy refractive surgery centers. DESIGN: Retrospective study. PARTICIPANTS: Twelve thousand six hundred sixty-eight Navy and Army sailors and service members. METHODS: Army and Navy refractive surgery data banks were searched for cases of infectious keratitis. A retrospective chart review and query of the surgeons involved in the care of those patients thus identified provided data regarding preoperative preparation, perioperative medications, treatment, culture results, clinical course, and final visual acuity. RESULTS: Between January 1995 and May 2004, we performed a total of 25337 PRK procedures at the 6 institutions. Culture proven or clinically suspected infectious keratitis developed in 5 eyes of 5 patients. All patients received topical antibiotics perioperatively. All cases presented 2 to 7 days postoperatively. Cultures from 4 cases grew Staphylococcus, including 2 methicillin-resistant S. aureus (MRSA). One case of presumed infectious keratitis was culture negative. There were no reported cases of mycobacterial or fungal keratitis. In addition, we identified 26 eyes with corneal infiltrates in the first postoperative week that were felt to be sterile, and which resolved upon removal of the bandage contact lens and increasing antibiotic coverage. CONCLUSIONS: Infectious keratitis is a rare but potentially vision-threatening complication after PRK. It is often caused by gram-positive organisms, including MRSA. Early diagnosis, appropriate laboratory testing, and aggressive antimicrobial therapy can result in good outcomes.

Long-term graft survival in patients with Down syndrome after penetrating keratoplasty.

PURPOSE: To determine graft survival and long-term visual outcome after penetrating keratoplasty (PK) for keratoconus in patients with Down syndrome. METHODS: The records of all patients with Down syndrome who received PK by the same provider were reviewed. A retrospective analysis was performed to determine long-term graft survival, incidence of graft failure, and complication rate. RESULTS: Twenty-one PKs were performed on 18 eyes of 13 patients with Down syndrome with keratoconus. Three repeat PKs were performed for secondary graft failure. All 18 eyes had clear grafts at the most recent examination. Follow-up ranged from 4 to 88 months, with a mean of 34.9 months. The average age of patients was 42 years, with a range of 20 to 63 years. Preoperative visual acuity ranged from 20/160 to count fingers. Postoperatively, visual acuity was objectively measurable in 12 eyes of 8 patients and ranged from 20/30 to 20/200, with a mean of 20/60. Broken sutures and difficulties with unsedated suture removal complicated postoperative care in some patients. CONCLUSION: Clear grafts and improvements in visual acuity can be obtained after PK in patients with Down syndrome, but consideration must be given to careful postoperative care by health care providers and home support personnel.

Anterior segment imaging in combat ocular trauma.

Purpose. To evaluate the use of ocular imaging to enhance management and diagnosis of war-related anterior segment ocular injuries. Methods. This study was a prospective observational case series from an ongoing IRB-approved combat ocular trauma tracking study. Subjects with anterior segment ocular injury were imaged, when possible, using anterior segment optical coherence tomography (AS-OCT), confocal microscopy (CM), and slit lamp biomicroscopy. Results. Images captured from participants with combat ocular trauma on different systems provided comprehensive and alternate views of anterior segment injury to investigators. Conclusion. In combat-related trauma of the anterior segment, adjunct image acquisition enhances slit lamp examination and enables real time In vivo observation of the cornea facilitating injury characterization, progression, and management.

Visual and anatomic outcomes of vitrectomy with temporary keratoprosthesis or endoscopy in ocular trauma with opaque cornea.

BACKGROUND AND OBJECTIVE: To examine the outcomes of vitrectomy in ocular trauma with opaque cornea. PATIENTS AND METHODS: This retrospective study included 17 eyes of 16 patients who underwent vitrectomy with temporary keratoprosthesis or endoscopy at Walter Reed Army Medical Center, Washington, DC, from March 2003 to October 2010. RESULTS: A temporary keratoprosthesis was used in 8 eyes (47%) and endoscopy in 9 eyes (53%). Overall, the number of eyes with visual acuity of 20/200 or better improved from 0 at baseline to 5 (29%) at 6 months. The number of eyes with retinal detachment also improved from 10 (59%) at baseline to 3 (18%) at 6 months. CONCLUSION: Vitrectomy may be safely performed in ocular trauma with opaque cornea using a temporary keratoprosthesis or endoscopy with comparable outcomes. Endoscopy allows earlier diagnosis and treatment of occult pathology and requires less time and fewer procedures to implement than the temporary keratoprosthesis.

Residency training in refractive surgery.

PURPOSE: To evaluate resident refractive surgery caseload and surgical outcomes in an academic medical center. SETTING: Walter Reed Army Medical Center, Washington, DC, USA. DESIGN: Comparative case study. METHODS: Keratorefractive procedures performed by residents at the Walter Reed Center for Refractive Surgery between 2002 and 2010 were reviewed. Outcomes of surgeries performed by the graduating classes of 2008 to 2010 were compared with those of cases performed by staff. The uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent, corrected distance visual acuity (CDVA), and complications were analyzed. RESULTS: Between 2002 and June 2010, residents performed 1566 procedures (1414 photorefractive keratectomy [PRK], 152 laser in situ keratomileusis), for a mean of 20.2 procedures from 2002 to 2004, 51.6 from 2005 to 2007, and 99.9 from 2008 to 2010. Outcomes analysis was performed on 333 resident eyes and 977 staff eyes treated between 2008 and June 2010. Six months postoperatively, 96.1% of resident-treated eyes and 94.6% of staff-treated eyes had a UDVA 20/20 or better (P=.312) and 61.3% and 64.3%, respectively, had a UDVA 20/15 or better (P=.324). The percentage of eyes within ±0.50 diopter of emmetropia at 6 months was 94.0% for residents and 91.1% for staff (P=.105). The postoperative CDVA was within 2 lines of preoperative baseline in all resident cases and 99.8% of staff cases (P=.999). CONCLUSIONS: Resident experience grew steadily over the period studied. Overall safety and efficacy of resident-performed surgery, albeit mainly PRK based, matched that of fellowship-trained refractive surgeons. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Photorefractive keratectomy in posterior polymorphous dystrophy with vesicular and band subtypes.

PURPOSE: To evaluate the safety and efficacy of photorefractive keratectomy (PRK) in patients with posterior polymorphous dystrophy (PPMD) with vesicular and band subtypes. SETTING: Walter Reed Center for Refractive Surgery, Washington, DC, USA. DESIGN: Case series. METHODS: The records of patients with PPMD who had PRK between January 2002 and May 2009 were reviewed. Data for analysis included sex, age, ablation depth, residual stromal bed thickness, manifest spherical equivalent, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, central corneal thickness (CCT), endothelial cell density (ECD), intraocular pressure (IOP), and complications. Preoperative and postoperative results were compared using the Wilcoxon signed-rank test, with P < .05 considered significant. RESULTS: Fourteen eyes of 7 men (mean age 29.1 years ± 9.1 [SD]; range 21 to 42 years) with at least a 6-month follow-up were reviewed. At the final follow-up (mean 19.5 months; range 6.3 to 58.3 months), all eyes had a UDVA of 20/15 and all eyes were within ± 0.50 diopter of emmetropia. The CDVA was unchanged from preoperatively in 71.4% of eyes and improved by 1 line in 28.6%. There were no significant complications. The IOP did not change significantly over the follow-up (P = .272). At the final visit, the mean ECD (2795.3 ± 366.0 cells/mm(2)) was unchanged from baseline (2809.1 ± 338.3 cells/mm(2)) (P = .114). CONCLUSIONS: Photorefractive keratectomy in PPMD patients with vesicular and band subtypes resulted in excellent visual outcomes and a low incidence of adverse effects. Endothelial cell densities did not change significantly in the early postoperative period. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Treatment of inflammatory macular edema with humanized anti-CD11a antibody therapy.

PURPOSE: To evaluate the safety and efficacy of treating macular edema, secondary to noninfectious uveitis, with a humanized anti-CD11a antibody. METHODS: Six patients received weekly subcutaneous treatments for 16 weeks according to this open-label, prospective, noncomparative phase I/II trial. Best corrected visual acuity (BCVA) and central macular thickness (CMT) were compared to baseline. Adverse events were recorded and assessed. Blood was sampled to assess the levels of CD56(bright) regulatory NK cells before initiation and after termination of the study. RESULTS: No serious adverse events were reported by the patients. Patients' ages ranged from 22 to 82 years. Mean BCVA improvements were 6.7 ± 6.9 ETDRS letters in the worse eye and 1.7 ± 5.2 letters in the better eye. Mean CMT reductions were 128 ± 105 µm in the worse eye and 57 ± 68 µm in the better eye. Anti-CD11a antibody treatments resulted in an increase in the CD56(bright) regulatory NK cell population in the peripheral blood of the patients. CONCLUSIONS: Anti-CD11a treatment improved visual function, reduced macular thickness, and increased the level of CD56(bright) regulatory NK cells in patients with uveitic macular edema refractory to other immunosuppressive medications. Targeting CD11a may be beneficial in treating other causes of macular edema.