Charles Bonnet Syndrome in a Patient With Acute Glaucoma Following Carotid Endarterectomy.

Acute neovascular glaucoma is an extremely rare complication following carotid artery revascularization that can lead to permanent vision loss. We describe an unusual case of acute glaucoma following carotid endarterectomy presenting with mechanical pupillary dilation and vivid visual hallucinations consistent with the Charles Bonnet Syndrome. This case highlights the importance of screening patients complaining of vision loss or eye pain for neovascular eye changes prior to carotid revascularization. These patients' eye health should be closely monitored peri-operatively.

Multicenter, Head-to-Head, Real-World Validation Study of Seven Automated Artificial Intelligence Diabetic Retinopathy Screening Systems.

OBJECTIVE: With rising global prevalence of diabetic retinopathy (DR), automated DR screening is needed for primary care settings. Two automated artificial intelligence (AI)-based DR screening algorithms have U.S. Food and Drug Administration (FDA) approval. Several others are under consideration while in clinical use in other countries, but their real-world performance has not been evaluated systematically. We compared the performance of seven automated AI-based DR screening algorithms (including one FDA-approved algorithm) against human graders when analyzing real-world retinal imaging data. RESEARCH DESIGN AND METHODS: This was a multicenter, noninterventional device validation study evaluating a total of 311,604 retinal images from 23,724 veterans who presented for teleretinal DR screening at the Veterans Affairs (VA) Puget Sound Health Care System (HCS) or Atlanta VA HCS from 2006 to 2018. Five companies provided seven algorithms, including one with FDA approval, that independently analyzed all scans, regardless of image quality. The sensitivity/specificity of each algorithm when classifying images as referable DR or not were compared with original VA teleretinal grades and a regraded arbitrated data set. Value per encounter was estimated. RESULTS: Although high negative predictive values (82.72-93.69%) were observed, sensitivities varied widely (50.98-85.90%). Most algorithms performed no better than humans against the arbitrated data set, but two achieved higher sensitivities, and one yielded comparable sensitivity (80.47%, P = 0.441) and specificity (81.28%, P = 0.195). Notably, one had lower sensitivity (74.42%) for proliferative DR (P = 9.77 × 10-4) than the VA teleretinal graders. Value per encounter varied at $15.14-$18.06 for ophthalmologists and $7.74-$9.24 for optometrists. CONCLUSIONS: The DR screening algorithms showed significant performance differences. These results argue for rigorous testing of all such algorithms on real-world data before clinical implementation.

Off-Label Use of Phakic Intraocular Lens with a "Piggyback" Technique.

PURPOSE: We report a case of a highly myopic pseudophakic patient who received off-label placement of a phakic intraocular lens (pIOL) via a "piggyback" technique, allowing the placement of an intraocular lens (IOL) in his fellow eye, resulting in improved visual acuity and emmetropia. CASE REPORT: A 66-year-old, highly myopic, pseudophakic male with an IOL implant in his left eye was referred for second opinion for surgical options for his phakic right eye. Given the severe myopic status of both eyes, he received off-label placement of a posterior chamber pIOL with a piggyback technique for the pseudophakic left eye followed by standard cataract surgery and intraocular lens implantation in the right eye. For the left eye, uncorrected best visual acuity improved from 20/70 to 20/25. CONCLUSION: This case demonstrates the successful off-label use of a phakic IOL in a pseudophakic, highly myopic patient with a piggyback technique, resulting in improved visual acuity and ultimately allowing IOL placement in the fellow eye for emmetropia. This off-label use of pIOL can offer ophthalmologists an alternative option for pseudophakic patents with severe refractive error.

Cataract Surgery following Sequential Myopic and Hyperopic LASIK.

We report a case of patient dissatisfaction after sequential myopic and hyperopic LASIK in the same eye. We discuss the course of management for this patient involving eventual cataract extraction and intraocular lens (IOL) implantation with attention to the IOL power calculation method used.

Posterior Wall Collapse in High Myopia following Cataract Surgery.

PURPOSE: We report a case of posterior globe collapse of an eye after initial recovery from uncomplicated cataract surgery in a patient with high myopia and discuss the course of management involving recognition and emergent air injection with globe reformation. CASE REPORT: A 64-year-old functionally monocular male with a history of high myopia presented for follow-up after uncomplicated cataract surgery. Uncorrected distance visual acuity (UCDVA) at postoperative day 1 was 20/150 with an intraocular pressure (IOP) of 19 mm Hg. At the week 1 visit, UCDVA had decreased to 20/200 with an IOP at 9 mm Hg. After preliminary exam, the keratome site suture was removed, after which the patient reported vision changes. A dilated fundus exam was performed revealing posterior scleral wall collapse. A clinical diagnosis of hypotony was made and a pars plana injection of 1 mL air was performed. This resulted in immediate subjective improvement of vision. Exam the next day revealed UCDVA 20/50 with pinhole improvement to 20/30 and IOP 15 mm Hg. CONCLUSION: This case demonstrates postoperative hypotony in a patient with pathologic myopia, following cataract surgery. Pathologically myopic eyes may have greater propensity to collapse in the setting of reduced IOP.

Comparison of optical biometry versus ultrasound biometry in cases with borderline signal-to-noise ratio.

PURPOSE: To ascertain if optical biometry determination of axial length (AL) and intraocular lens (IOL) power is significantly different compared to ultrasound (US) biometry in cases with borderline signal-to-noise ratio (SNR). PATIENTS AND METHODS: Sixty patients who had cataract and IOL Master biometry with borderline SNR (1.6-2.0) were included. A retrospective chart review was performed to compare data collected with optical biometry and US biometry in cataract cases with borderline SNR. RESULTS: Results showed that optical biometry IOL and AL measurements were not significantly different from the US measurements. Analysis also demonstrated good agreement between the two methods. CONCLUSION: Our study suggests that, in cases of borderline quality data, IOL power and AL measurements with optical biometry are still useful in surgical planning and that additional US measurements may be used more as a corroborative tool.

Bilateral Uveitis and Keratitis Following Nivolumab Treatment for Metastatic Melanoma.

BACKGROUND: Inflammatory eye disease has been reported as a side effect with Nivolumab. CASE PRESENTATION: We report a case of a 92-year-old woman presenting with bilateral and simultaneous keratitis and uveitis in the setting of recurring infusions of nivolumab for metastatic melanoma. The patient underwent successful coordinated treatment of both eyes coinciding with ongoing systemic infusion treatments with ophthalmic topical medications alone. CONCLUSION: The interest of this case resides in the simultaneous nature of presentation of eye inflammation both internally and of the ocular surface. Prior case reports have cited uveitis or ocular surface disease, however not in simultaneous fashion. Clinicians should raise their index of suspicion of side effects of nivolumab systemic infusion for any vision or eye symptom changes around the timing of treatment.